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'-^■TMif^i  -  I    .  ,. 


as  t^liirsea.^e  of  the  Masses 
and  How  to  Combat  It 


or  TME  INTERNATIONAL  TÜEEStCüLOS!S  CONGRESS 


PRIZE  ESS4 


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Berlin..   IS99 


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mzw  YORK 


WURTH  AMERICAN  EDITION 


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Columbia  ®mtiers;itp 

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AND   SURGEONS 


Reference  Library 

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TUBERCULOSIS 


AS  A  DISEASE  OF  THE  MASSES 
AND  HOW  TO  COMBAT  IT 

FOURTH     ISSUE     REVISED 
AND    ILLUSTRATED 

With  Supplement  on  Home  Hygiene,  School 
Hygiene,  Installation  of  the  Sanatorium 
Treatment  at  Home,  and  a  Histor-  - 
ical  Review  of  the  Anti-Tu- 
berculosis Movement  in 
the   United   States 

Motto :  To  combat  consumption  as  a  disease  of  the  masses 
successfully;  requires  the  combined  action  of  a  wise  govern- 
ment, well  trained  physicians,  and  an  intelligent  people. 

PRIZE   ESSAY 

BY 

S.  A.  KNOPF,  M.D.,  New  York 

Director  in  the  National  Association  for  the  Study  and  Prevention  of  Tuberculosis ;   Associate 
Director  of  the  Clinic  for  Pulmonary  Diseases  of  the   Health  Department ; 

Visiting  Physician  to  the  Riverside  Sanatorium  for  Con-  R 

sumptives  of  the  City  of  New  York,  etc.  " 


The   "  International  Congress  to    Combat   Tuberculosis   as    a    Disease  of   the 
Masses,"   which    convened   at   Berlin,    May    24    to    27,    1899,   awarded   the       ]| 
International    Prize  to   this   work   through    its    Committee   on   July  31,    1900 

AMERICAN    EDITIONS 
First  Issue.   1901  ;     Reprinted,  1 903  ;     Reprinted,  1 905  ;        Revised  with  Supplement,  1907 


Published  by  FRED.  P.  FLORI,  514  E.  82nd  St.,  New  York 
Also  for  Sale  by 

"CHARITIES   AND   THE   COMMONS" 

105    East    22nd    Street,    New   York   City     1907 


rwwworarwsrarararMMrarararwarwarjrarararwarararwjrwdraracarxwjr 


4 


Copyright,  1 90 1 
ByS.  A.  KNOPF,  M.D. 

NEW  YORK 


LIST  OF  TRANSLATIONS 


The  American  edition  is  translated  by  the  Author  and  published 

by  Fred.  P.  Flori,  514  East  82d  Street,  New  York. 
The  Arabic  Edition  is  translated  by  Dr.  Mary  P.  Eddy,   Beirut, 

Syria,  and  published  by  the   Board  of  Foreign   Missions  of 

the  Presbyterian  Church. 
The  Brazilian  edition  is  translated  by  Dr.  Clemento  Ferreira,  and 

published  by  the  "  Revista  Medica  de  Sao  Paulo,"  Brazil. 
The  Bulgarian  edition  is  translated  and  published  by  Professor 

A.  Bezenseck,  of  Philippopel. 
The  Dutch  edition  is  translated  by  Dr..  J.  W.   F.   Donath,  and 

published  by  F.  Van  Rossen,  Amsterdam. 
The  English  edition  is   adapted   for  use   in  England  by    Dr.  J. 

M.    Barbour,    and   published   by   Rebman,    Limited,    129 

Shaftesbury  Avenue,  London. 
The  Finnish  edition  is  translated  by  Dr.  Johannes  Moving  and 

L.    Rosendahl,    F.M.,     and    published  by    Dr.    Joiiannes 

Hoving,  New  York. 
The  French  edition  is  translated  by  Dr.  G.  Sersiron,  and  pub- 
lished at  Paris  by  G.  Masson,  120  Boulevard  Saint  Germain. 
The  German  edition  is  published  by  the  "German  Central  Com- 
mittee for  the  Combat  of  Tuberculosis,"  at  Berlin,  9  Eich- 
horn Strasse. 
The  Hebrew  edition  is  translated  by  Dr.   L.  W.  Zwisohn,  and 

published  by  E.  Zunser,  158  East  Broadway,  New  York. 
The  Hungarian  edition  is  translated  by  Dr.  Wm.  Roth-Schulz, 

and  published  by  Mai  Henrik  es  Fia,  Budapest. 
The  Icelandic  edition  is  translated   by  Dr.  G.  Björnsson,  and 

published  by  the  Danish  Government  at  Reykjavik. 
The  Italian  edition  is  translated  by  Prof.   Dr.   Roberto  Massa- 

longo,  of  Verona,  and  published  at   Milan  by  Francesco 

Valardi. 
Another  Italian  edition  is  translated  by  Dr.  Giovanni  Galli,  and 

published  by  the  Societa  Editrice  Dante  Alighieri,  at  Rome. 
The  Japanese   edition   is  translated   by  Dr.    Goro  Shibayama, 

Tokio. 
The  Mexican  edition  is  translated  by  Dr.  D.  Vergara  Lope,  and 

published  by  Eduardo  Murguia,  Mexico. 
The  Polish  edition  is  translated  by  Dr.    Stanislaus  Lagowsky, 

and  publisiied  by  E.  Wende  i  S-ka,  Warsaw. 
The  Russian  edition  is  translated  by  Dr.  F.  M.  Blumenthal,  and 

published  under  tiie  auspices  of  the  Pirogoff   Society   of 

Russian  physicians  by  A.  A.  Levenson,  at  Moscow. 
The  Second  Russian  edition  is  translated  by  B.  I.  Wender,  and 

published  by  P.  I.  Makuschin,  Tomsk,  Siberia. 
The  Serbian  edition  is  translated  by  Drs.  V.  P.  Popovic  and  V. 

Vojislav  Mihailovic,  Graz,  and  published  by  Paher  &  Kicic, 

at  Mostar. 
The  Spanish   edition  is  translated   by  Dr.  Ernesto   Sanchez  y 

Rosal,  and  published  by  Ern.st  Litfass'  Erben,  Berlin  C. 
The  Swedish  edition  is  translated  and  published  by  Dr.Johannef 

Hoving,  New  York. 
The  Turkish   edition   is  translated  by  Dr.   Mary  P.  Eddy,   of 

Beirut,  Syria,  and  published  by  the  Translator. 


PREFACE"  TO  THE  GERMAN  EDITION. 

fBy  Geh.  Med. -Rath  Professor  B.  FRÄNKEL,  of  Berlin,  Germany,  setting 
forth  the  conditions  under  which  the  prize  was  awarded.) 


At  the  meeting  of  the  "International  Congress  for  the  Study 
of  the  Best  Way  to  Combat  Tuberculosis  as  a  Disease  of  the 
Masses "  which  convened  at  Berlin,  May  24-27,  1899,  the  sum 
of  4,000  marks  was  donated  by  two  Berlin  merchants,  lay  mem- 
bers of  the  Congress,  as  a  prize  to  be  offered  for  the  best  essay  on 
the  subject  "Tuberculosis  as  a  Disease  of  the  Masses  and  How  to 
Combat  It "  ("  Die  Tuberkulose  als  Volkskrankheit  und  deren 
Bekämpfung  "). 

The  Congress  decided  on  the  following  regulations  concerning 
this  prize : 

1.  The  best  popular  essay  on  the  subject  "Tuberculosis  as  a  Disease 

of  the  Masses  and  How  to  Combat  It,"  comprising  not  more 
than  eighty,  and  not  less  than  forty-eight,  printed  pages,  shall 
receive  the  prize  of  4,000  marks.  In  case  the  jury  of  the 
prize  committee  should  decide  that  two  essays  deserve  the 
prize,  the  best  may  receive  3,000  marks,  and  the  second  best 
1,000  marks.  Or,  should  the  decision  of  the  judges  find  two 
essays  of  equal  value,  each  shall  receive  2,000  marks. 

2.  The  following  gentlemen  have  consented  to  act  as  judges :  Ge- 

heimrath  Prof.  Dr.  B.  Fränkel;  Geheimrath  Prof.  Dr.  Ger- 
hardt; Kapitän  z.  S.  Harms;  WirkL  Geh.  Ober  Peg. -Path 
Präsident  Köhler;  Generalarzt  Prof.  Dr.  von  Leuthold, 
Excellenz;  Geheimrath  Prof.  Dr.  von  Leyden;  Freiherr  Dr. 
Lucius  von  Ballhausen,  Excellenz;  Geheimrath  Dr.  Nau- 
mann ;  Oberstabsarzt  Dr.  Pannwitz ;  Dr.  Graf  von  Posadow- 
sky-Wehner,  Excellenz;  Se.  Durchlaucht  der  Herzog  von 
Eatibor. 


4  PREFACE  TO   THE   GERMAN  EDITION. 

3.  All   essays   must   be  sent  by  December   1,  1899,  to  Privy- 

Councillor  Prof.  Dr.  B.  PrUnkel,  4  Bellevue  Strasse,  Berlin, 
and  each  essay  must  bear  a  motto,  selected  by  the  writer, 
who  shall  insert  his  name  within  a  sealed  envelope  having  the 
motto  on  the  cover. 

4.  The  essay,  or  essays   (see  §  1),  to  which  has  been  awarded 

the  prize,  become  the  property  of  the  "German  Central  Com- 
mittee for  the  Erection  of  Sanatoria."  The  latter  will  take 
upon  itself  the  printing  of  the  essay  and  the  least  expensive 
method  of  distribution. 

5.  The  decision   of  the  judges  is  to  be  announced  through  the 

public  press. 

The  foregoing  regulations  were  published  in  the  medical  and 
lay  papers,  and  as  a  result  eighty-one  essays  were  received  by 
December  1st.  The  essays  were  distributed  among  the  judges 
with  the  request  to  select  from  them  such  as  were  deserving  of 
closer  examination.  The  judges  recommended  twenty-six  for  that 
purpose. 

The  fifty-five  rejected  essays  were  once  more  examined  by  the 
undersigned  and  his  assistants,  Drs.  Edmund  Meyer,  Alexander, 
Finder,  Claus,  and  Elwert,  but  these  gentleineu  could  not  recom- 
mend any  of  the  fifty-üve  essays  for  further  consideration. 

At  the  meeting  of  the  jury  on  February  25,  1900,  under  the 
presidency  of  his  Serene  Highness  the  Duke  of  Eatibor,  it  was 
decided  that  the  twenty-six  selected  essays  should  be  once  more 
carefully  examined  by  Drs.  Frankel,  Gerhardt,  Harms,  Köhler,  von 
Leuthold,  von  Ley  den,  Freiherr  von  Lucius  and  Pannwitz,  and  the 
result  was  that  three  were  ultimately  selected  for  closer  choice. 

At  the  next  meeting  of  the  judges,  on  June  15th,  it  was  decided 
to  form  a  sub-committee  composed  of  Drs..  Fränkel,  Gerhardt, 
Harms,  Köhler,  and  Pannwitz,  to  decide  upon  final  action.  After 
careful  consideration  this  committee  came  to  the  conclusion  that 
the  work  bearing  the  motto, 

"To  combat  consumption  successfully  requires  the  combined  action  of  a 
wise  government,  well-trained  physicians,  and  an  intelligent  people," 

SO  much  surpassed  all  the  others  in  excellence,  that  it  should  be 


PREFACE    TO   THE   GERMAN   EDITION.  5 

awarded  the  Congress  prize.     It  was  then  found  that  Dr.  S.  A. 
Knopf,  of  New  York,  was  the  author  of  this  work. 

A  few  changes,  as  recommended  by  the  judges,  were  accepted  by 
Dr.  Knopf,  and  have  been  incorporated  in  the  present  work. 

At  a  subsequent  meeting  of  the  German  Central  Committee  it 
was  resolved  to  publish  this  essay  and  arrange  for  its  widest  dis- 
tribution. 

Pkofessor  B.  TeSneel. 

Berlin,  October  1,  1900. 


PREFACE  TO  THE  FIRST  ISSUE  OF  THE 
AMERICAN  EDITION. 

In  presenting  to  the  English-speaking  world,  and  particularly 
to  the  people  of  the  United  States,  a  translation  of  the  essay, 
originally  written  in  German,  the  author  desires  to  state  that, 
while  having  endeavored  to  make  as  exact  a  translation  as  possi- 
ble, he  found  it  necessary  to  change  several  passages,  making 
some  additions  and  omissions.  His  reasons  for  having  done  so 
will  be  obvious  to  all  who  have  studied  pulmonary  tuberculosis  or 
consumption,  not  only  in  its  medical,  but  also  in  its  sociological 
aspects,  and  who  wül  bear  in  mind  the  fact  that  the  habits  of  na- 
tions differ,  and  that  in  a  popular  essay  it  is  absolutely  necessary  to 
take  these  differences  into  account.  Thus  it  was  even  necessary, 
before  the  original  German  essay  could  appear  in  print,  that  the 
author  should  consent  to  make  certain  changes  bearing  on  the 
particular  local  conditions  and  situation  of  the  consumptive  poor 
in  Germany.  These  changes  were  suggested  in  detail  by  the 
judges  who  awarded  the  prize.  With  a  generosity  which  cannot 
be  lauded  too  highly,  these  gentlemen  did  not  expect  to  find  in  the 
essays,  submitted  to  them  for  competition  from  all  over  the  world, 
a  complete  knowledge  of  the  sanitary  laws  and  regulations  which 
are  now  in  vogue  in  the  German  empire,  nor  did  they  expect  the 
essayists  to  be  familiär  with  local  conditions  to  the  extent  of 


6        PREFACE  TO  THE  ENGLISH  TRANSLATION. 

knowing  all  that  would  or  would  not  be  practicable  in  the  carry- 
ing out  of  suggestions  to  prevent  the  spread  or  the  development  of 
tuberculous  diseases. 

The  social  conditions  in  Germany  differ  very  much  from  those 
in  the  United  States,  and  the  author  felt  it  his  duty  to  speak  in 
this  American  edition  of  all  the  important  points  bearing  directly 
on  the  question  of  tuberculosis  as  a  "  social  disease  "  in  America. 
The  evils  of  alcoholism,  of  the  overcrowding  of  tenement  houses 
and  of  unsanitary  dwellings  of  the  poor  in  general,  also  some  of 
the  causes  of  malnutrition  or  underfeeding  of  the  laboring  classes, 
are  treated  as  fully  as  the  nature  of  such  an  essay  permits. 

As  an  example  of  the  necessity  of  making  certain  changes  in 
this  work,  intended  for  an  American  public,  I  may  be  permitted 
to  state  the  following :  in  Germany  every  laboring  man  and  wom- 
an must  be  insured  against  old  age,  accident,  and  disease,  includ- 
ing tuberculosis,  and  the  employer  is  held  responsible  for  the 
compliance  with  this  law.  No  such  laws  exist  in  the  United 
States,  where  even  private  insurance  companies  will  not  insure  a 
tuberculous  invalid.  As  another  illustration  of  the  vastly  different 
conditions  here  and  in  Germany  regarding  our  subject,  we  must 
consider  that  every  one  of  the  forty-seven  States  of  the  Union  has 
its  own  sanitary  laws  and  regulations.  They  differ  widely  in  rigor 
and  completeness  in  regard  to  the  prevention  of  tuberculosis  in 
man  as  well  as  in  beast.  In  Germany  there  is  one  homogeneous 
law  for  all  the  states  and  provinces ;  there  is  a  ministry  for  "  Medic- 
inal Angelegenheiten  "  (medical  affahs)  with  a  cabinet  officer  at 
the  head,  who  has  for  his  advisers  the  highest  medical  authorities 
connected  with  the  "  Eeichs-Gesundheitsamt "  (imperial  office  of 
health).  I  hope  the  time  is  not  far  distant  when  our  own  be- 
loved country  will  have  similar  institutions ;  when  all  the  State, 
coimty,  and  city  boards  of  health  will  look  to  Washington,  the 
seat  of  the  future  secretary  of  public  health,  as  their  supreme  head 
and  guide  in  medical  and  sanitary  matters.  In  the  mean  time  let 
us  labor  as  best  we  can;  let  each  State,  county,  and  city  board  of 
health  do  its  best  toward  an  intelligent,  rigorous,  and  yet  not  too 
oppressive  public  prophylaxis  of  bovine  and  human  tuberculosis ; 
and  let  the  people  at  large  lend  a  willing  hand  in  this  combat 
against  our  common  foe,  the  "Great  White  Plague." 

S.  A.  Knopf,  M.D. 

16  West  Ninety-fifth  Stbebx,  New  Yobk,  January,  1901. 


PREFACE  TO  THE  FOURTH  ISSUE  OF  THE 
AMERICAN  EDITION. 


After  three  issues  of  the  American  edition  of  this  essay  have 
been  printed  without  any  material  change  from  the  original  trans- 
lation of  the  German  edition,  I  am  confronted  with  the  problem 
of  either  writing  a  new  edition  or  making  a  supplement  which  will 
contain  what  is  new  and  of  interest  to  the  Medical  Profession  and 
the  Public.  I  have  decided  to  present  the  matter  in  the  form  of 
a  supplement  which  will  contain  what  had  to  be  left  out  of  the 
original  edition  because  the  jury  of  the  Berlin  tuberculosis  congress 
limited  the  number  of  printed  pages,  and  also  the  most  important 
things  that  the  experience  of  seven  more  years  in  tuberculosis 
work  has  taught  me.  Thus  I  have  added  two  paragraphs,  one  on 
Home  Hygiene,  and  one  on  School  Hygiene.  An  equally  valuable 
addition  I  hope  will  be  found  in  the  chapter  added  on  the  Instal- 
lation for  the  Sanatorium  Treatment  at  Home..  Lastly,  there 
will  be  a  short  historical  review  of  the  anti-tuberculosis  movement 
in  the  United  States  from  its  beginning  to  the  present  day. 

My  reason  for  adding  these  four  new  chapters  in  the  form  of  a 
supplement,  instead  of  inserting  them  in  the  text,  is  purely  an  eco- 
nomical one.  Inserting  them  would  increase  the  cost  of  the  book 
materially,  while  by  writing  a  supplement  the  book  can  still  be 
sold  at  retail  for  $0.25  paperbound  and  $0.50  clothbound,  and  at 
wholesale  correspondingly  cheaper.  There  are  enough  good  books 
on  tuberculosis  in  the  market  costing  $2.00,  $3.00,  and  $5.00,  in- 
tended to  inform  the  layman;  but  for  the  masses,  who  need  this 
information  most,  there  are  few  at  a  price  within  their  reach. 

In  this  connection  I  must  explain  why  this  essay  has  not  been 
published  by  one  of  the  well-known  firms  handling  medical  and 
popular  scientific  books.  The  low  price  at  which  I  insisted  the 
book  should  be  put  on  the  market  seemingly  did  not  insure  sufR- 


8  PEEFACE  TO  THE  AMERICAN  TRANSLATION. 

cient  remuneration  to  the  various  firms  to  whom  I  applied.  But 
I  was  fortunate  enough  to  interest  a  former  secretary  of  mine,  Mr. 
Fred.  P.  Flori,  who  has  undertaken  the  pubUshing  and  selling  of 
the  book  at  this  low  price.  I  desire  to  thank  him  for  the  interest 
and  devotion  which  he  has  brought  to  the  task. 

I  must  not  send  out  this  little  volume  without  expressing  my 
sincerest  thanks  and  appreciation  to  Drs.  Barbour,  Bezenseck, 
Björnsson,  Blumenthal,  Donath,  Eddy,  Ferriera,  Galli,  Hoving, 
Lagowsky,  Lope,  Massalongo,  Mihailovic,  Popovic,  Rosendahl, 
Roth-Schulz,  Rosal,  Sersiron,  Shibayama,  Wender,  and  Zwieshon, 
who  have  honored  me  by  translating  the  essay  into  their  native 
languages.  "  Tuberculosis  as  a  Disease  of  the  Masses  and  How  to 
Combat  it"  is  now  printed  in  twenty-one  dilTerent  languages,  thus 
reaching  people  in  all  parts  of  the  civilized  world. 

It  is  particularly  gratifying  to  me  that  the  much  needed  infor- 
mation which  this  little  book  is  intended  to  give,  has  been  so  far- 
reaching.  The  original  German  edition  has  been  reprinted  many 
times  and  largely  distributed  by  the  German  Government,  for 
which  I  have  now  a  second  edition  in  preparation.  Five  thousand 
copies  of  this  present  issue  are  to  be  sent  to  the  Health  Officers 
of  this  State  for  distribution.  I  wish  to  thank  Dr.  Eugene  H.  Porter, 
the  present  Commissioner  of  the  Department  of  Health  of  the  State 
of  New  York,  for  his  efforts  in  causing  this  to  be  done,  thus  giving 
his  official  approval  to  the  work  and  furthering  education  in  the 
prevention  of  tuberculosis  throughout  the  Empire  State. 

May  this  fourth  issue,  which  I  trust  is  enhanced  in  value  by  the 
supplement,  meet  with  the  same  kind  reception  that  has  been 
accorded  to  the  previous  editions,  and  may  the  information  which 
the  book  is  intended  to  convey  be  helpful  to  physicians  and  patients, 
teachers  and  parents,  statesmen,  employers  and  employees,  to  rich 
and  poor,  in  short  to  all  able  and  willing  to  help  in  the  solution 
of  the  tuberculosis  problem,  and  thus  add  to  the  health,  prosperity 
and  happiness  of  all  the  people.  S.  A.  KNOPF,  M.D. 

16  West  Ninety-fifth  Street,  New  Yobk,  April  1,  1907 


TABLE  OF  CONTENTS. 


CHAPTER  PAGE 

Preface  to  the  German  Edition 1 

Preface  to  the  First  Issue  of  the  American  Edition     5 

Preface  to  the  Fourth  Issue  of  the  American  Edition  (with  Sup- 
plement)    7 

Introduction 11 

I.  What  Is  Consumption  ? 15 

II.  How  may  the  Germ  of  Consumption  (Bacillus  Tuberculosis)  Enter 

the  Human  System  ? 16 

III.  How  does  the  Inhalation  of  the  Bacilli  Take  Place  ? 16 

IV.  What  must  be  Done  to  Check  the  Spread  of  Consumption  Caused 

by  the  Expectoration  of  Pulmonary  Invalids  ? 17 

A.  Destruction  of  Tuberculous  Expectoration. 

B.  Disinfection  of  the  Sick-Room. 

V,  What  can  be  Done  to  Protect  Oui'selves  from  the  Small  Particles  of 
Saliva  Containing  Bacilli,  Thrown  Out  by  the  Consumptive  Dur- 
ing Dry  Cough,  Loud  Speaking,  or  Sneezing  ? 23 

VI,  How  may  Man  Give  Tuberculosis  to  Animals  ? 24 

VII.  How  can  We  Guard  Against  Germs  of  Tuberculosis  in  Our  Pood  ?    25 
VIII.  In  What  Other  Ways  may  the  Bacilli  or  Germs  of  Consumption 

Enter  the  Intestinal  Tract  ? 26 

IX.  How  may  Tuberculosis  be  Contracted  through  Inoculation  (Pene- 
tration of  Tuberculous  Substances  through  the  Skin)? 27 

X.  What  Other  Forms  of  Tuberculosis  Exist,  and  What  are  Their 

Principal  Symptoms  ? 28 

XI.  Wliat  Protects  the  Healthy  Individual  from  Contracting  Tubercu- 
losis ? 30 

XII.  How  may  One  Successfully  Overcome  a  Hereditary  Disposition  to 

Consumption  ? 31 

XIII.  How  can  a  Predisposition  to  Tuberculosis,  Other  than  Hereditary, 

be  Created  or  Acquired  ? 41 

XIV.  How  may  an  Acquired  Predisposition  be  Overcome,  and  Seemingly 

Unhealthy  Occupations  Me^de  Relatively  Harmless  ? 42 

XV.  What  can  Weil-Meaning  and  Conscientious  Employers  in  City  and 

Country  Do  to  Help  Combat  Tuberculosis  ? 43 

XVI.  What  can  the  Farmer  and  Dairyman  Do  to  Diminish  the  Frequency 
of  Tuberculosis  among  Animals,  and  Thus  Indirectly  Stop  the 
Propagation  of  the  Disease  among  Men  ? 45 

XVII,  What  are  the  Occupations  in  Which  Tuberculous  Invalids,  Even 

in  the  First  Stages  of  the  Disease,  Should  Not  be  Employed  ?. .     55 

XVIII.  What  are  the  Main  Signs  and  Symptoms  of  the  Beginning  of  Tuber- 
culosis of  the  Lungs  or  Consumption  ? 56 


10  TABLE   OP   CONTENTS. 

CHAPTER  PAGE 

XIX.  What  are  the  Early  Symptoms  of.  Other  Formis  of  Tuberculosis  ?     57 
XX.  How  can  Children  be  Protected  from  Scrofula  and  Other  Eorms 

of  Tuberculosis  ? 59 

XXI.  Can  Tuberculosis,  Especially  in  Its  Pulmonary  Form,  or  Con- 
sumption of  the  Lungs,  be  Cured? 61 

XXII.  Have  the  Former  Patients  Who  Left  Sanatoria  or  Special  Insti- 
tutions for  the  Treatment  of  Consumption  as  Cured,  Remained 
Lastingly  So  ? 62 

XXIII.  What  are  the  Modern  Methods  to  Treat  and  Cure  Consumption  ?    63 

XXIV.  What  is  a  Modern  Sanatorium  for  Consumpti  ves?    And  can  Such 

a  Sanatorium  Become  a  Danger  to  the  Neighborhood  ? 65 

XXV.  What  are  State  Sanatoria?    And  What  are  "Volksheilanstalten" 

or  People's  Sanatoria  ? 71 

XXVI.  What  Evidence  Exists  That  by  Taking  Care  of  Consumptives  in 
Special  Institutions  and  by  Hygienic  Measures,  Tuberculosis 
as  a  Disease  of  the  Masses  can  Really  be  Successfully  Com- 
bated ? 72 

XXVII.  Can  the  Treatment  of  Consumption  be  Carried  Out  with  Satis- 
factory Results  Outside  of  an  Institution  ? 73 

XXVIII.  What  can  Philanthropists  and  Other  Men  and  Women  of  Good 
Will  Do  to  Help  Combat  Tuberculosis  as  a  Disease  of  the 

Masses  ? 76 

XXTX.  How  Might  the  Tuberculosis  Problem  in  the  United  States  be 
Solved  by  Judicious  Legislation  and  a  Combination  of  Public 

and  Private  Philanthropy  ? 80 

XXX.  Conclusions 85 

SUPPLEMENT. 

A.  Home  Hygiene  to  Prevent   Tuberculosis 87 

B.  School  Hygiene  as  a  Factor  in  the  Prevention  of  Tuberculosis. . .     89 

C.  Installation  for  the  Sanatorium  Treatment  of  Consumptives  at 

Home ^^ 

D.  Historical  Review  of    the  Antituberculosis  Movement  in    the 

United  States 101 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 
AND  HOW  TO  COMBAT  IT. 


mTEODUCTIOK 


Tuberculosis  has  been  called  a  disease  of  the  masses  on  account 
of  its  gi-eat  prevalence  among  aR  classes  of  people.  It  has  been 
known  for  hmidreds  of  years  as  the  most  feared,  most  prevalent, 
and,  alas !  also  as  the  most  fatal  of  all  diseases.  Hippocrates,  the 
most  celebrated  physician  of  antiquity  (460  to  377  B.c.),  and  the 
true  father  of  scientific  medicine,  described  pulmonary  tuberculosis 
or  consumption  as  the  disease  which  is  "  the  most  difB.cult  to  treat, 
and  which  proves  fatal  to  the  greatest  number."  Isocrates,  also  a 
Greek  physician,  who  lived  about  the  fifth  century  before  Christ, 
was  the  first  to  write  of  tuberculosis  as  a  disease  transmissible 
through  contagion.  In  the  middle  ages  (1550)  the  celebrated 
physician  Montano  declared  consumption  to  be  one  of  the  most 
dangerously  contagious  and  most  easily  contracted,  of  diseases.  An 
equally  strong  advocate  of  the  theory  of  contagion  was  the  cele- 
brated anatomist  Morgagni  (1682-1771),  who  never  performed  an 
autopsy  on  an  individual  who  had  died  from  tuberculosis.  Toward 
the  end  of  the  eighteenth  century  the  sanitary  authorities  of  some 
cities  of  Italy  and  France  considered  consumption  a  highly  in- 
fectious and  contagious  disease,  and  a  French  medical  author  of 
the  name  of  Janett  de  Langrois  reports  that  the  municipal  au- 
thorities of  Nancy  had  caused  the  furniture  and  bedding  of  a  wom- 
an who  had  died  from  consumption,  to  be  destroyed  by  fire.  The 
contagion  in  this  case  had  actually  been  demonstrated,  inquiries 
revealing  that  the  deceased  woman  had  slept  frequently  with  a 
consumptive  girl  friend  until  she  finally  succumbed  to  the  same 
disease. 


12  TUBERCULOSIS   AS  A   DISEASE   OF  THE  MASSES 

In  Naples  a  royal  decree,  dated  September  20,  1782,  ordered 
the  isolation  of  consumptives  and  the  disinfection  of  their  apart- 
ments, personal  effects,  furniture,  books,  etc.,  by  means  of  vinegar, 
brandy,  or  lemon  juice,  sea-water,  or  fumigation.  Any  violation 
of  this  law  was  punished,  if  the  individual  was  an  ordinary  mor- 
tal, with  three  years  in  the  gaUeys,  and  if  he  happened  to  be  a 
nobleman  he  was  sent  for  the  same  time  to  the  fortress  and  had 
to  pay  300  ducats.  The  physician  who  faüed  to  notify  the  au- 
thorities of  the  existence  of  a  tuberculous  patient  was  fined  300 
ducats  for  the  first  offence,  and  a  repetition  of  the  neglect  would 
banish  him  from  the  country  for  ten  years.  According  to  Portal 
(1742-1832),  there  was  a  law  in  Spain  and  Portugal  which  obliged 
the  parents  or  nearest  relative  of  a  consumptive  to  notify  the  au- 
thorities when  the  patient  had  arrived  at  the  last  period  of  the  dis- 
ease. This  was  done  for  the  purpose  of  making  sm^e  of  the  disin- 
fection of  the  personal  effects  of  the  patient  after  his  death. 

In  the  first  half  of  the  nineteenth  century  little  attention  was 
paid  to  the  infectious  theory  of  tuberculosis  even  by  medical  men. 
The  contagiousness  or  communicability  of  the  disease  could  not  be 
scientifically  demonstrated,  and  although  there  were  physicians 
here  and  there  who  believed  in  the  infectiousness  of  the  disease, 
nothing  positive  was  taught  in  regard  to  it  at  the  centres  of  medi- 
cal learning. 

At  last,  in  186.5,  the  French  physician  Villimin  demonstrated 
beyond  a  shadow  of  doubt  that  tuberculosis  could  be  transmitted 
from  one  individual  to  another.  He  inoculated  animals  with  tu- 
berculous substances  and  reproduced  tuberculosis  not  only  in  the 
lungs  but  also  in  other  portions  of  the  body.  Since  this  discovery 
and  its  verification  by  numerous  experimenters,  such  as  Cohnheim, 
Welch,  Prudden,  Straus,  and  others,  it  has  been  generally  ac- 
knowledged that  tuberculosis  is  an  infectious  disease,  and  that  for 
its  production  a  specific  germ  is  essential.  The  discovery  of  this 
specific  organism  (bacillus  tuberculosis)  was  reserved  to  the  gi-eat 
German  scientist  Eobert  Koch  (1882). 

Consumption  is  an  endemic  disease,  that  is  to  say,  habitually 
prevalent,  and  it  exists  m  all  civilized  countries.  Wild  tribes  and 
less  civilised  people  succumb  to  the  disease,  as  a  rule,  very  rapidly 


AND   HOW  TO   COMBAT   IT. 


13 


as  soon  as  they  come  in  contact  with  civilization.  The  proof  of 
this  we  might  find  among  the  North  American  Indians  and  among 
the  negi'oes  and  their  descendants  now  livmg  in  the  United  States. 
According  to  the  recent  report  of  the  Board  of  Health  of  Toronto 
(Canada),  pulmonary  tuberculosis  is  dangerously  prevalent  among 
the  Blood  Indians  of  the  Dominion  of  Canada.  Of  every  hundred 
deaths  which  occm-red  among  this  tribe  in  the  year  1898,  twenty- 
three  were  due  to  consumption.  Since  these  Indians  are  kept  on 
a  reservation  under  the  supervision  of  the  Canadian  Government, 
these  statistics  should  be  considered  reliable. 

The  mortality  from  tuberculosis  among  the  colored  population  of 
the  United  States  is  nearly  twice  that  of  the  white  population. 
However,  let  us  state  right  here  that  the  cause  of  this  increased 
mortality  among  Indians  and  negroes  is  to  be  ascribed  not  to  the 
blessings  of  civilisation,  but  rather  to  the  vices,  such  as  alcoholism 
and  excesses  of  all  kinds,  which,  alas !  too  often  accompany  civil- 
izing agents. 

There  have  been  so  many  statistics  published  concerning  the 
general  mortality  from  tuberculosis  in  the  United  States  and  Eu- 
rope, that  we  do  not  think  it  necessary  to  reproduce  in  detail  any 
of  the  published  tables,  but  will  content  ourselves  with  some  gen- 
eral statements.  It  is  now  universally  admitted  that  tuberculosis 
is  the  most  frequent  cause  of  death.  According  to  some  statistics 
every  seventh,  according  to  others  every  sixth,  death  is  due  to  tu- 
berculosis in  one  form  or  other.  According  to  Dr.  George  F. 
Keene,  of  Ehode  Island,  who  is  a  very  close  observer,  the  annual 
tribute  of  the  United  States  to  this  scourge  is  over  100,000  of  its 
inhabitants.  Each  year  the  world  yields  up  1,095,000,  each  day 
3,000,  each  minute  2  of  its  people  as  a  sacrifice  to  this  plague. 

Tuberculosis  occurs  most  frequently  in  its  pulmonary  form,  com- 
monly known  as  consumption.  According  to  the  Imperial  Sani- 
tary Office  of  Berlin,  thirteen  per  cent,  of  the  deaths  (during  the 
years  from  1888  to  1892)  were  due  to  pulmonary  consumption. 
However,  it  must  be  stated  that  of  late  the  mortality  from  tuber- 
culosis has  decreased  in  some  European  and  American  cities  (Ber- 
lin, London,  New  York,  Philadelphia,  etc.),  thanks  to  better  pre- 
ventive measures  and  more  rational  methods  of  treatment.     In  one 


Consump- 
tion an 

Endemic 
Disease. 


A  Few 

Statistics. 


14 


TUBERCULOSIS  AS  A  DISEASE   OP  THE  MASSES 


SIS. 


of  the  succeeding  chapters  we  shall  speak  more  in  detail  of  public 
prophylaxis  and  special  institutions  for  consumptives  in  the  combat 
against  tuberculosis.  In  relation  to  statistics  we  desii'e,  lastly,  to 
mention  only  some  interesting  facts  gleaned  from  a  pamphlet  pub- 
lished last  year  by  the  Imperial  Health  Office  of  Berlin.  Accord- 
ing to  this  latest  report  the  mortality  from  tuberculosis  is  greatest 
in  Eussia  and  Austria,  being  more  than  3,500  per  million  inhabi- 
tants. It  is  lowest  in  England,  being  less  than  1,500  per  million. 
Germany  occupies  about  the  middle,  while  France  comes  immedi- 
ately after  Austria.* 

The  researches  of  recent  years  have  demonstrated  that  consump- 
tion and  also  many  other  forms  of  tuberculosis  may  not  only  be 
prevented,  but  can  in  many  cases  be  arrested  and  lastingly  cured. 
The  governments  and  the  medical  profession  are  aware  of  this,  and 
have  laboriously,  energetically,  and  most  unselfishly  worked  in  the 
direction  of  solving  this  important  problem,  which  means  so  much 
to  the  welfare  of  the  people.  The  Congresses  for  the  Study  of 
Tuberculosis,  which  have  met  biennially  since  1888  in  Paris;  the 
International  Congress,  which  convened  at  Berlin  in  May,  1899, 
under  the  protection  of  her  Majesty  the  Empress  of  Germany,  and 
the  Italian  Congi^ess,  which  was  called  together  for  the  same  pur- 
pose last  year  in  Naples,  give  the  best  proof  of  the  zeal  of  the 
medical  profession  and  the  governments  to  combat  tuberculosis 
with  all  possible  means. 

But,  as  the  motto  of  this  essay  expresses  it,  the  intelligent  co- 
operation of  the  people  ia  this  work  is  indispensable.  To  enable 
all  men  and  women  to  participate  intelligently  in  this  combat 
against  a  common  foe  is  the  purpose  of  this  essay. 

We  shall  now  give  a  brief  description  of  the  form  of  tuberculosis 
known  as  tuberculosis  of  the  lungs,  pulmonary  tuberculosis,  or 
consumj)tion. 

*  The  United  States  was  not  included  in  this  table,  but  would  probably 
come  close  to  Germany. 


AND  HOW   TO   COMBAT  IT. 


15 


CHAPTER   I. 

What  is  Consumption? 


Pulmonary  consumption,  or  tuberculosis  of  the  lungs,  is  a  chronic 
disease  caused  by  the  presence  of  the  tubercle  bacillus,  or  germ 
of  consumption,  in  the  lungs.  The  disease  is  locally  charac- 
terized by  countless  tuber- 
cles, that  is  to  say,  small 
rounded  bodies,  visible  to  the 
naked  eye.  The  bacilli  can 
be  found  by  the  million  in 
the  affected  organ.  It  is 
this  little  parasite,  fungus, 
or  mushroom,  belonging  to 
the  lowest  scale  of  vegetable 
life,  which  must  be  consid- 
ered as  the  specific  cause  of 
all  tuberculous  diseases.  This 
parasite  not  only  gradually 
destroys  the  lung  substance 
through  ulcerative  processes, 
but  gives  off  at  the  same  time  certain  poisonous  substances  called 
toxkis  which  give  rise  to  various,  and  often  serious,  symptoms. 

The  important  symptoms  of  pulmonary  tuberculosis  are  cough, 
expectoration  (spittiug  phlegm),  fever  (increased  temperature  of 
the  body,  especially  in  the  eveniug  hours),  difficulty  in  breathing, 
pains  in  the  chest,  night-sweats,  loss  of  appetite,  hemorrhages  (spit- 
ting of  blood),  and  emaciation  (loss  of  flesh). 

In  the  matter  expectorated,  it  is  often  possible  to  find  the  tubercle 
bacillus  with  the  aid  of  the  microscope  and  certain  coloring  matters. 
It  appears  in  the  form  of  smaU,  slender  rods.  To  give  an  idea  of  the 
minute  size  of  these  bacilli  or  bacteria,  we  reproduce  here  what  is 
called  a  microscopic  field  twelve  hundred  times  enlarged ;  in  other 
words,  just  what  one  sees  after  having  prepared  a  smaU  portion 
of  expectorated  tuberculous  matter  under  the  microscope.      The 


Fig.  1.— Tubercle  Bacilli  in  ExpectxDrated  Matter. 
1,200  times  enlarged. 


16 


TUBERCULOSIS  AS   A  DISEASE   OF  THE   MASSES 


rods  represent  the  bacilli;  the  round  or  in-egnlar  bodies  represent 
other  substances  which  have  been  ejected  along  with  the  bacilli 
(Fig.  1). 

CHAPTEE   II. 

How   MAY    THE    GeRM    OF    CONSUMPTION     (BACILLUS    TUBERCU- 
LOSIS) Enter  the  Human  System? 

1.  By  being  inhaled;  that  is,  breathed  into  the  lungs. 

2.  By  being  ingested ;  that  is,  eaten  with  tuberculous  food. 

3.  By  inoculation ;  that  is,  the  penetration  of  tuberculous  sub- 
stance through  a  wound  in  the  skin. 

Of  these  three  ways  in  which  the  bacilli  may  enter,  the  first  one 
seems  to  be  the  most  important. 


CHAPTEE   III. 

How   DOES    THE    INHALATION    OF   THE    BACILLI   TaKE   PlACE? 

A  consumptive  individual,  even  at  a  period  when  he  is  not  con- 
fined to  his  bed,  may  expectorate  enormous  quantities  of  bacilli. 
Now  if  this  expectoration,  or  spittle,  is  carelessly  deposited  here 
and  there,  so  that  it  has  an  opportunity  to  dry  and  become  pulver- 
ized, the  least  draught  or  motion  iu  the  air  may  cause  it  to  mingle 
with  the  dust,  and  the  individual  breathing  this  dust-laden  atmos- 
phere is  certainly  exposed  to  the  danger  of  becoming  tuberculous, 
if  his  system  offers  a  favorable  soil  for  the  growth  of  the  bacilli. 
By  "  favorable  sou  for  the  gi-owth  of  the  bacilli "  must  be  understood 
any  condition  in  which  the  body  is  temporarily  or  permanently  en- 
feebled. Such,  a  condition  may  be  inherited  from  parents,  or  ac- 
quired through  alcoholism  or  drunkenness  or  other  intemperate 
habits,  through  privation  or  disease. 

Besides  the  danger  arising  from  carelessly  deposited  sputum,  or 
spittle,  the  inhalation  or  ingestion  of  the  small  particles  of  saliva 
which  may  be  expelled  by  the  consumptive  during  his  so-called 
dry  cough,  or  when  speaking  quickly  or  loudly,  or  when  sneezing, 
must  also  be  considered  as  dangerous  for  those  who  come  in  close 


AND  HOW  TO   COMBAT  IT.  l7 

contact  with  the  invalid.  These  almost  invisible  drops  of  saliva 
may  contain  tubercle  bacilli.  Eecent  experiments  in  this  direc- 
tion have  shown  the  possibility  of  infection  by  this  means. 


CHAPTEE   IV. 

What  must  be  Done  to  Check  the  Speead  of  Consumption 
Caused  by  the  Expectoration  of  Pulmonary  Invalids  ? 

A.  Destruction  of  Tuberculous  Expectoration. — Consumptives 
and  those  living  with  them  must  know  that  all  precautionary  meas- 
ures are  instituted  in  the  interest  of  the  invalid  as  well  as  of  his 
fellowmen.  These  measures  protect  the  patient  from  reinfection 
and  others  from  the  danger  of  contracting  the  disease. 

A  patient  suffering  from  pulmonary  consumption  should  know 
that,  no  matter  in  what  stage  of  the  disease  he  may  be,  his  expec- 
toration or  spittle  may  spread  the  germ  of  the  disease  if  the  matter 
expectorated  is  not  destroyed  before  it  has  a  chance  to  dry  and  be- 
come pulverized.  The  patient  should,  therefore,  always  spit  in  some 
receptacle  intended  for  the  purpose.  It  is  best  to  have  this  vessel 
made  of  metal  so  as  not  to  break.  It  should  be  half  filled  with 
water  or  some  disinfecting  fluid,  the  main  thing  being  to  make  it 
impossible  for  the  expectoration  to  dry. 

In  factories,  stores,  railroad  cars,  waiting-rooms,  court-rooms, 
restaurants,  saloons,  meeting-places,  theatres,  menageries — in  short, 
wherever  many  people  congregate — ^there  should  be  a  sufficient 
number  of  cuspidors  well  kept  and  regularly  cleaned.  They 
should  be  made  of  unbreakable  material  and  have  wide  openings. 
If  such  measures  are  carried  out,  there  will  be  no  excuse  for  any 
one  to  expectorate  on  the  floor  and  thus  endanger  the  lives  of  his 
fellow-men. 

In  the  sick-room  of  a  private  home,  at  hospitals  or  sanatoria, 
only  covered  cuspidors  should  be  used,  and  it  is  better  to  have  them 
placed  on  stands,  in  niches,  or  in  elevated  boxes.  We  give  an  ex- 
ample of  the  last-named  kind  in  Fig.  2,  showing  a  blue  enamelled 
iron  spittoon  in  a  box  elevated  on  a  stand.  The  spittoon  is  fast- 
ened by  a  clamp  to  the  door  of  the  box,  and  can  be  easuy  removed 
2 


18 


TUBERCULOSIS   AS  A  DISEASE   OP  THE  MASSES 


for  cleaning.  The  stand  is  most  convenient  when  about  three  feet 
in  height.  Such  an  arrangement,  besides  making  it  more  sure  that 
the  sputum  will  all  reach  the  inside  of  the  spittoon,  has  the  addi- 
tional pleasant  feature  of  making 
the  cuspidor  visible  only  while 
it  is  being  used  by  the  patient. 
The  cover  of  the  receptacle  pre- 
vents flies  and  other  insects  from 
coming  in  contact  with  the  spu- 
tum. It  has  been  proved  that 
insects,  especially  flies,  often  carry 
the  bacillus  out  of  the  sick-rooms 
of  consumptives  when  sufficient 
care  is  not  taken  to  cover  the  ex- 
pectoration. The  fly  which  has 
come  in  contact  with  tuberculous 
matter  may  spread  the  disease  in 
three  ways.  First,  it  may  carry 
small  particles  of  spittle  on  its  feet, 
and  leave  them  wherever  it  may 
alight.  Secondly,  if  it  has  partaken 
of  tuberculous  matter,  it  deposits 
its  excrement  at  the  next  oppor- 
tunity on  some  article  of  food,  and 
thus  the  bacilli 
find  their  way  into  the  digestive  organs  of  man 
or  beast.  Thirdly,  these  insects  may  dry  and 
trumble  to  dust  which  contains  the  bacilli,  and 
the  germs  of  the  disease  may  thus  enter  tlie 
lungs. 

The  cuspidor  of  metal  elevated  and  covered, 
presents  further  advantages  over  the  usual  un- 
covered vessel  of  porcelain  or  earthenware.  Ani- 
mals, such  as  dogs,  cats,  etc.,  will  not  be  able 
to  reach  the  contents  of  the  cuspidor ;  and  there 
is  less  danger  of  its  bursting  when  placed  out- 
doors at  freezing  temperature  if  enclosed  in  a  box.    ^^^-  ^-  ~^n^"^''^  ^p**" 


Fig.  2.— Elevated  Spittoon. 


AND  HOW  TO   COMBAT  IT. 


Id 


Fig.  5  a.— Knopf 's  Nickel- 
plated  Flask  (Closed) . 


Fig.  4.— Dettweiler's 
Pocket  Flask. 


For  factories,  workshops,  etc.,  Predohl's  enamelled  iron  spittoon, 
nine  inches  high,  eight  inches  in  its  largest  and  three  inches 
in  its  smallest  diameter, 
seems  to  answer  all  prac- 
tical purposes.  As  the 
accompanying  drawing 
(Fig.  3)  indicates,  it  can 
be  suspended  atany  height, 
and  is  very  easily  cleaned 
and  disinfected. 

AVTien  outdoors,  the  pa- 
tient should  use  a  pocket 
flask  to  receive  the  spittle. 
There  are  numerous  flasks 
in  the  market,  and  I  repro- 
duce a  few  of  them :  Dett- 
weiler's,  of  blue  glass  and 
in  three  pieces  (Fig.  4)  ;  Knopf  s,of  nickel-plated 
metal  (Figs.  5  and  6);  Liebe' s,  of  blue  glass 
in  two  pieces  (Fig.  7).  The  dh-ections  for  use  usually  accompany 
each  flask.  The  more  expensive  ones  (Figs.  4  and  5)  can  be 
manipulated  with  one  hand.     The  cleaning  of 

all  of  them  is  easy.     The 

expectoration  received  in 

any    receptacles,    large 

spittoons  or  pocket  flasks, 

should  be  so  disposed  of 

that  the  bacilli  are  killed. 

Wliere    there    is  a  good 

sewerage  system  the  con- 
tents of  these  cuspidors 

may,  without  danger,  be 

poured   into    the  water- 
closet.     Where  there  are 

no    running    water    and 
perfect  sewerage,  it  is  better  to  boü  the  con-     pj,..  6._Knoprs  Aiumi- 
tents  of  the  spittoons  before  pouring  them  into       coTCn''^'^ ^"'^  ^'^*° 


Fig.  5  ?j.— Funnel  and  Cover 
to  Fig.  5  n. 


Pocket 
Spittoons. 


20 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


the  water-closet,  or  disposing  of  them  otherwise.     Thus,  whenever 

possible,  the  tuberculous  expectoration,  that  is  to  say,  tlie  entire 

contents  of  all  classes  of  cuspidors,  should  be  placed  in  a  pot 

kept  for  that  purpose  which  is  partially  filled 

with  water.     Every  twenty-four  hours  or  so  this 

pot  should  be  put  on  the  fire  and  the  contents 

brought  to  a  boil.     To  raise  the  boiKng  point  it 

might  be  well  to  add  to  each  quart  of  water  one 

or  two  teaspoonfuls  of  washing  soda.     After  the 

mixtm-e  has  boiled  for  about  five  minutes,  it  can 

be  considered  totally  harmless,  for  all  the  ba- 

' '"spittoon.  cilli  will  have  been  killed.     The  disinfection  of 

tuberculous  expectoration  by  carbolic  acid  (5  per  cent.)  or  mercu- 

Disinfec-      ^^^^  solutions  (1 : 2,000)  is  not  so  certain,  since  these  substances 

tion  and     cause  the  albumen  in  the  expectoration  to  coagulate,  and  thus 

Destruction  form,  in  a  measure,  a  protective  cover  for  the  bacilli  and  make 

Tiibereu-     ^^^^  total  destruction  more  difficult. 
lousMatter.   vinegar  is  a  better  and  more  con- 
venient disinfectant  and  need  not 
be  diluted  when  used. 

When  people  are  so  situated 
as  not  to  be  able  to  dispose  of 
the  contents  of  the  pocket  spittoons 
by  boiling  or  disinfection,  we 
would  recommend  the  following 
method :  poiu*  the  contents  of  the 
flask  on  several  layers  of  news- 
per,  gathering  up  the  edges  and 
being  careful  not  to  spill  any,  and 
throw  the  whole  at  once  into  the  fire. 
A  handkerchief  should  never  be 
used  as  a  receptacle  for  sputum.  Patients  who  are  too  sick  to 
make  use  of  light  porcelain  or  aluminum  cups  (Fig.  8),  Seabury 
&  Johnson's  spitting-cup  of  pasteboard  (Fig.  9),  or  the  Kny- 
Scheerer  pressed-paper  cup  (Fig.  10)  should  have  a  number  of  moist 
rags  within  easy  reach.  Care  should  be  taken  that  the  rags  always 
remain  moist,  and  that  the  used  ones  aie  burned  before  they  have 


Ordinary  conmiercial  wood 


Fig.  8.— Spit-Cup  of  Aluminum  or  Porce- 
lain. 


AND  HOW  TO   COMBAT  IT. 


21 


a  chance  to  dry.  The  paper  spit-cujjs  with  their  contents  should, 
of  course,  also  be  destroyed  by  fire. 

There  will  always  be  some  consumptives  who  cannot  be  per- 
suaded to  use  the  pocket  flask,  for  the  simple  reason  that  they  do 
not  wish  to  draw  attention  to  their 
malady.  The  only  thing  for  these 
people  to  do  is  to  use  squares  of  soft 
muslüi,  cheese-cloth,  cheap  handker- 
chiefs, or  Japanese  paper  handker- 
chiefs specially  manufactured  for  that 
purpose,  which  can  be  burned  after 
use.-  They  should  also  place  in  theii- 
pockets  a  removable  lining  of  rubber 
or  other  impermeable  substance  which 
can  be  thoroughly  cleaned.  This  ad- 
ditional pocket  could  be  fastened  to 
the  inside  of  the  ordinary  pocket  by 

clamps,  and  would  thus  be  of  no  inconvenience  to  the  patient. 
A  pouch  of  vulcanized  rubber  or  an  Oriental  tobacco-pouch  may 
be  used  in  place  of  the  extra  pocket  of  impermeable  material. 


Fig.  9  a.— Frame  of  Seabury  &  John- 
son's Spitting-Cup. 


Fig.  9  b.— Folded  Cardboard,  to 
be  Burned  Alter  Use. 


Fig.  10.— Kny-Sclieerer's  Sanitary  Spittoon  Cup. 


In  any  case  it  is  weU.  to  have  more  than  one  of  these  pockets 
or  pouches,  so  that  the  patient  is  never  without  one  while  they 
are  being  cleaned  and  immersed  in  some  disinfectant  solution  or 
boiling  water.  Of  course,  all  invalids  using  handkerchiefs,  rags, 
or  Japanese  paper  as  receptacles  for  expectoration,  are  in  danger  of 


22  TUBERCULOSIS  AS  A  DISEASE   OF  THE   MASSES 

infecting  their  hands,  and  should  always  wash  them  thoroughly 
before  touching  food. 

B.  Disinfection  of  the  Sick-Boom. — The  rooms  occupied  by  a 
tuberculous  patient  should  be  thoroughly  disinfected  at  regular  in- 
tervals, since  it  is  possible  that  even  with  great  care  the  furniture, 
floors,  walls,  etc.,  may  have  been  infected.  Even  the  occasional 
disinfection  of  the  personal  effects  of  the  patient  is  advisable.  In 
case  of  decease  it  is,  of  course,  self-understood  that  everything  the 
consumptive  might  have  come  in  contact  with,  particularly  furni- 
ture, bedding,  clothing,  books,*  etc.,  should  be  thoroughly  disin- 
fected. In  many  communities  such  disinfection  is  now  attended 
to  by  the  board  of  health.  Where  the  aid  of  the  health  board 
caunot  be  secured,  the  following  directions  will  enable  one  to  make 
a  thorough  disinfection  by  formaldehyde  gas:  1.  All  cracks  or 
formalde-  openings  in  the  plaster,  in  the  floor,  or  about  the  doors  and  win- 
-..  7  „  dows  should  be    caulked    tight   with   cotton    or   strips  of  cloth, 

tion  of  2.  The  linen,  quilts,  blankets,  carpets,  etc.,  should  be  stretched 
Rooms,  etc.  out  on  a  line  in  order  to  expose  as  much  surface  as  possible  to  the 
disinfectant.  They  should  not  be  thrown  into  a  heap.  Books 
should  be  suspended  by  theh  covers,  so  that  the  pages  will  fall 
open  and  be  freely  exposed.  3.  The  walls  and  the  floor  of  the 
room  and  the  articles  contained  in  it  should  be  thoroughly  sprayed 
with  water.  If  masses  of  matter  or  sputum  are  dried  on  the  floor, 
they  should  be  soaked  with  water  and  loosened.  No  vessel  of 
water  should,  however,  be  allowed  to  remain  in  the  room.  4. 
One  hundred  and  fifty  cubic  centimeters  (five  ounces)  of  the  com- 
mercial forty-per-cent.  solution  of  formalin  for  each  one  thousand 
culjic  feet  of  space  should  be  placed  in  the  distilling  apparatus  and 
be  distilled  as  rapidly  as  possible.  The  keyhole  and  spaces  about 
the  door  should  then  be  packed  with  cotton  or  cloth.  5.  The  room 
thus  treated  should  remain  closed  at  least  ten  hours.  If  there  is 
much  leakage  of  gas  mto  the  surrounding  rooms,  a  second  or  third 
distillation  of  formaldehyde  should  be  made  at  intervals  of  two  or 
three  hours. 

*The  possibility  of  transmitting  tuberculosis  through  books  has  been  de- 
monstrated, particularly  if  the  patient  has  been  in  the  habit  of  moistening  his 
fingers  with  saliva  while  turning  the  leaves. 


AND  HOW  TO   COMBAT  IT.  23 

To  be  sure  that  the  work  is  well  done,  it  is  always  best  to  have 
it  supervised  by  a  physician.  To  managers  of  hotels  and  boarding- 
houses  in  health  resorts,  this  method  of  disinfection  is  particularly 
to  be  recommended,  and  the  disinfection  of  rooms  occupied  by  con- 
sumptive guests  should  always  take  place  immediately  after  their 
removal. 

In  some  cities  and  villages  tuberculosis  seems  to  cling  to  certain 
localities  and  houses.     The  disease  appears  in  a  veritable  endemic 
form,  that  is  to  say,  it  is  always  present  there,  either  from  the  fact  Permanent- 
that  careless  tuberculous  patients  have  lived  for  years  in  these  ly  Infected 
houses,  or  owing  to  the  equally  important  fact  that  the  soil  on      -H-ouses. 
which  they  are  built,  or  the  manner  in  which  they  have  been  con- 
structed, is  such  as  to  favor  the  retention  of  the  tuberculous  infec- 
tion indefinitely.     When  a  thorough    sanitary   overhauling   does 
not  suffice  to  stamp  out  these  sources  of  infection,  the  destruction 
of  such  dwellings  seems  the  only  remedy. 

CHAPTEE  V. 

What  can  be  Done  to  Protect  Ourselves  from  the  Small 
Particles  of  Saliva  Containing  Bacilli,  Thrown  Out 
BY  the  Consumptive  during  Dry  Cough,  Loud  Speaking, 
OR  Sneezing? 

There  is  real  danger  from  this  source  of  infection  only  when 
one  remains  a  considerable  length  of  time  very  near  the  tuberculous 
patient  while  he  coughs  or  speaks.  At  a  distance  of  three  or  four 
feet  the  danger  practically  ceases.  The  relatively  few  baciUi  which 
are  expelled  with  the  saliva  during  the  dry  cough,  sneezing,  or  loud 
speaking,  are  probably  never  thrown  farther  than  three  feet,  and 
fall  rapidly  to  the  ground. 

But  even  the  lesser  danger  which  may  arise  from  the  bacilli 
having  fallen  to  the  floor  with  the  particles  of  saliva  must  be  pre- 
vented. They  must  not  be  allowed  to  accumulate  and  so  be  blown 
up  with  the  dust  into  the  air.  Therefore  the  floor  of  the  room  of 
a  tuberculous  patient  should  never  have  any  fixed  carpet ;  and  even 
the  wooden  floor  should  never  be  swept  with  a  broom,  but  should  be 
frec[uently  wiped  up  with  a  wet  cloth  or  with  crude  oil.    Dusty  fur- 


24 


TUBERCULOSIS  AS   A  DISEASE  OF  THE   MASSES 


Arrange- 
ment of  the 
Consump- 
tive's 
Boom, 


Precau- 
tions to  be 
taken  by 
Nurses. 


Precau- 
tions with 

the 
Washing. 


niture  should  be  cleaned  in  the  same  way.  Plush,  velvet,  or 
cloth-covered  fiirniture,  heavy  curtains  or  other  fancy  decorations, 
which  might  serve  as  dust-catchers,  should  not  be  allowed  in  the 
room  of  a  tuberculous  patient.  Leather-covered,  rattan,  and  plain 
wooden  furniture  are  certainly  the  best,  and  the  curtains  should 
always  be  of  washable  material.  Fancy  curtains  of  cloth,  velour, 
or  silk,  which  accumulate  dust  and  keep  the  air  and  sun  out  of  the 
rooms,  should  be  discarded. 

If  at  all  possible,  every  patient  should  have  his  own  room,  but 
he  should  always  have  his  own  bed.  For  a  well  person  to  sleep 
in  a  bed  very  close  to  a  tuberculous  patient  is  almost  as  danger- 
ous as  to  sleep  together  in  one  bed. 

Friends,  relatives,  and  nurses  should  not  remain  very  near  the 
patient  longer  than  necessary,  and  the  tuberculous  invalid  should 
be  urged  always  to  hold  a  handkerchief  before  his  mouth  and  nose 
while  coughing  or  sneezing.  He  should,  furthermore,  be  advised 
to  carry  two  handkerchiefs  with  him  always :  one  to  hold  before 
his  mouth  and  to  wipe  it  with  after  having  expectorated ;  the  other 
to  use  only  to  wipe  his  nose.  By  being  careful  with  the  use  of  his 
handkerchiefs,  the  danger  of  infecting  his  nose  and  bronchial  tubes 
will  be  materially  lessened. 

All  soiled  linen  (sheets,  pillow-ciases,  underwear,  napkins,  hand- 
kerchiefs, etc.)  used  by  the  consumptive,  should  not  be  handled 
more  than  necessary,  but  should  be  placed  in  water  as  soon  as 
possible  after  removal  from  bed  or  body.  It  is  better  to  wash 
these  articles  separately,  and  only  after  having  been  thoroughly 
boiled  should  they  be  put  with  the  common  laundry.  Wlierever 
it  is  not  possible  to  carry  out  these  precautionary  measures  in 
their  entirety,  one  should  strive  to  follow  them  as  far  as  it  is  m 
one's  power. 

CHAPTER   VI. 

How  MAY  Man  Give  Tubekculosis  to  Animals? 

In  one  of  the  preceding  chapters  we  have  spoken  of  the  im- 
portance of  elevated  spittoons  to  protect  domestic  animals,  such  as 
cats,  dogs,  etc.,  from  the  danger  of  becoming  tuberculous  by  lick- 
ing up  tuberculous  expectoration.     By  the  careless  expectorating 


AND   HOW  TO   COMBAT  IT. 


25 


of  consumptives  in  meadows,  fields,  or  stables,  animals  may  be- 
come infected  with  the  disease.  The  following  very  instructive 
fact  came  to  the  notice  of  the  author  of  this  essay :  In  an  institu- 
tion for  the  treatment  of  consumptives,  managed  by  Sisters  of 
Charity,  and  where,  I  am  sorry  to  say,  there  was  not  enough  strict 
medical  supervision,  there  existed  only  certain  rules  concerning  the 
care  of  the  expectoration  within  doors;  outside  of  the  institution 
the  patients  were  at  liberty  to  do  as  they  liked,  and  they  expec- 
torated wherever  they  pleased  in  their  daily  walks  in  the  near- 
by meadows.  A  neighboring  farmer  who,  some  time  before,  had 
bought  five  healthy  cows,  had  them  retested,  with  the  result  that 
two  were  found  to  be  tuberculous.  He  had  the  tuberculous  cows 
killed,  the  stable  cleaned  and  disinfected,  and  no  longer  allowed 
the  patients  of  the  neighboring  sanatorium  to  promenade  in  the 
meadows  where  his  cows  pastured,  and  no  more  tuberculosis  ap- 
peared among  his  cattle. 

Now,  although  it  is  true  that  the  sun  and  the  ah*  ultimately 
destroy  the  germs  of  the  tuberculous  sputum,  it  is  not  wise  to  rely 
upon  this.  Tuberculous  substances  may  do  harm  by  being  licked 
up  by  animals  before  the  sun  and  air  have  had  time  to  kill  the 
bacilli,  and  in  dark  and  damp  places  it  often  takes  a  long  time  be- 
fore atmospheric  influence  renders  the  tuberculous  matter  absolute- 
ly inoffensive. 

The  stools  of  patients  suffering  from  tuberculosis  of  the  intes- 
tines should  be  disinfected  by  a  five-per-cent.  solution  of  carbolic 
acid.  The  superficial  burying  of  tuberculous  meat  or  tuberculous 
expectorations  without  previous  thorough  disinfection  must  be 
considered  as  dangerous. 


Danger  of 
Superficial 
Burial  of 
Tubercu- 
lous 
Substances. 


CHAPTER  VII. 

How  CAN  We  Guard  Against   Geems  of  Tuberculosis  in 

Our  Food? 

\'\Tienever  one  is  not  reasonably  certain  that  the  meat  he  eats 
has  been  carefully  inspected  and  declared,  free  from  disease  germs, 
it  should  be  very  thoroughly  cooked.  By  this  means  one  is  cer- 
tain to  kill  all  the  dangerous  micro-organisms.     Against  the  sale 


26  TUBERCULOSIS  AS  A  DISEASE   OF  THE   MASSES 

of  tuberculous  milk  there  are  very  excellent  laws  in  some  States 
of  the  Union,  which  are  rigorously  enforced.  In  some  the  laws 
are  less  good,  and  in  some  there  are  no  laws  at  the  present  time. 

In  justice  to  farmers  and  dairymen  it  must,  however,  be  said 
that  there  are  many  who  do  their  very  best  to  protect  themselves 
and  theh  fellow-men  from  the  danger  of  tuberculosis.  They  have 
-their  cows  tested  regularly,  destroy  the  animals  which  are  found 
to  be  tuberculous,  and  keep  their  stables  and  utensus  for  milk  as 
clean  as  possible. 

Unless  one  can  be  reasonably  sure  that  the  cows  from  which  the 

milk  is  derived  are  healthy  and  not  tuberculous,  the  milk  should 

Boiling  or    be  boiled  or  sterilized  before  use,  more  especially  when  it  is  in- 

Sterilizmg    tended  as  food  for  children.     Milk  obtained  from  stores  and  from 
Milk 

milk  peddlers  should  invariably  be  submitted  to  boiling  or  steril- 
ization. When  milk  is  kept  slowly  boiling  for  five  minutes,  all 
the  bacilli  are  killed,  and  the  same  result  is  obtained  by  the  steril- 
izing process,  that  is  to  say,  to  keep  the  milk  heated  for  at  least 
half  an  hour  at  a  temperature  of  about  70°  C.  or  160°  F.  There 
are  now  in  the  market  a  number  of  cheap  and  practical  apparatuses 
for  sterilizing  milk,  which  can  be  obtained  at  almost  any  drug  store. 

CHAPTEE   VIII. 

In  What  Other  Ways  may  the  Bacilli  or  Germs  of  Con- 
sumption Enter  the  Intestinal  Tract? 

Since  the  tubercle  bacillus  may  be  found  in  the  saliva  of  a  tu- 
berculous patient,  it  is  best  never  to  kiss  such  a  person  on  the 
Infection  rn"utli.  The  habit  of  caressmg  or  kissing  domestic  animals  (par- 
by  Saliva,  rots,  canary-buds,  dogs,  cats),  many  of  whom  are  tuberculous,  is 
equally  dangerous,  for  through  such  habits  these  animals  can  cer- 
tainly transmit  tuberculosis  to  man. 

Tuberculous  patients  should  have  their  own  drinking  glasses, 
spoons,  forks,  etc. ;  or,  at  least,  all  table  utensils  which  have  served 
the  tuberculous  patient  should  be  boiled  after  use. 

The  patient  should  never,  out  of  false  modesty,  swallow  his  ex- 
pectoration. He  will  thus  avoid  the  danger  of  contracting  intes- 
tinal tuberculosis.     How  important  this  warning  is  may  become 


AND   HOW  TO   COMBAT  IT. 


27 


evident  from  observations  of  the  tuberculous  insane.  These  un-  Danger  of 
fortunate  people,  with  whom  hygienic  education  is  impossible,  Swallowing 
often  swallow  their  expectoration,  and  as  a  consequence  intestinal 
tuberculosis  or  consumption  of  the  bowels  is  very  frequent  among 
them.  Every  consumptive  patient  should  remember  never  to 
touch  food  before  having  washed  his  hands  very  thoroughly. 
Even  with  the  greatest  care,  it  is  possible  that  he  may  have  soiled 
his  hands  with  tuberculous  expectoration. 


Tubercu- 
lous 
Sputum. 


CHAPTER   IX. 

How  MAY  Tuberculosis  be  Contracted  through  Inocula- 
tion (Penetration  of  Tuberculous  Substances  through 
THE  Skin)? 

Inoculation  of  tuberculosis  happens  perhaps  most  frequently 
through  injmies  received  while  cleaning  nicked  or  chipped  glass  or 
porcelain  cuspidors  which  had  been  used  by  consumptives.  It  is 
also  possible  for  the  bacilli  to  enter  the  circulation  if  the  person 
cleaning  the  spittoons  happens  to  have  a  wound  or  open  sore  on 
his  hand.  Persons  entrusted  with  the  care  of  the  spittoons  in  a 
private  home  or  an  institution  for  consumptives  should  wear  rubber 
gloves  while  cleaning  these  vessels. 

At  times  the  patient  may  inoculate  himself  by  placing  an  acci- 
dentally injured  finger  in  his  mouth,  or  by  carelessly  soiling  an 
open  wound  with  his  expectoration. 

Physicians,  students  of  medicine  or  veterinary  science,  butchers, 
etc.,  are  also  exposed  to  the  danger  of  wounding  themselves  with 
instruments  which  may  have  come  in  contact  with  tuberculous 
matter.  Extreme  care  is  the  only  remedy  for  all  persons  thus 
exposed. 

If  one  has  been  unfortmiate  enough  to  receive  an  injury  and 
tuberculous  inoculation  is  feared,  the  best  thing  to  do  is  to  let  the 
wound  bleed  freely,  wash  it  thoroughly  with  water  that  has  been 
boiled,  with  a  five-per-cent.  solution  of  carbolic  acid,  or  with  pure 
alcohol;  dress  the  wound  with  a  clean  rag  dipped  in  any  of  these 
liquids,  and  seek  as  soon  as  possible  the  advice  of  the  physician. 

By  tattooing  tuberculosis  has  been  transmitted  in  various  ia- 


Care  to  be 
Taken  in 
Cleaning 
Spittoons. 


28       tubercutjOSis  as  a  disease  of  the  masses 


stances,  because  the  operator  was  a  consumptive.  Men  who  follow 
the  profession  of  tattooing  have,  as  a  rule,  the  habit  of  dissolving 
the  colors,  necessary  for  theii'  work,  with  their  own  saliva,  hence 
the  infection.  The  best  thing,  therefore,  is  never  to  permit  such 
barbaric  decorations  on  one's  body. 

Of  less  frequent  causes  of  propagating  tuberculosis,  but  which, 
in  the  light  of  modern  sanitary  science,  can  and  should  be  pre- 
vented, we  wül  cite  the  ritual  act  of  cii'cumcision,  practised 
according  to  Jewish  rites,  when  the  operator  happens  to  be  con- 
sumptive. It  is  also  well  known  that,  through  lack  of  skul  in 
after-treatment,  secondary  hemorrhage  and  wound  infection  have 
ensued.  Too  many  a  young  life  has  thus  been  needlessly  sacri- 
ficed. The  operation  of  circumcision,  when  skilfully  and  rapidly 
performed,  is  in  itself  trifling,  but  the  sucking  of  the  prepuce 
afterward  makes  it  dangerous.  Since  it  will  be  difficult  to  stop 
this  practice  by  a  simple  protest  on  the  part  of  physicians,  and  as 
the  law  cannot  interfere  with  the  free  exercise  of  a  religious  rite, 
I  should  suggest  as  a  remedy  that  only  such  persons  should  be 
allowed  to  perform  circumcision  as  have  shown  the  necessary  skul 
before  a  medical  board  of  examiners,  and  that  every  time  they  are 
called  upon  to  perform  the  rite,  they  should  submit  themselves  to 
a  medical  examination.  Only  when  bearing  a  certificate  from  a 
regular  physician,  stating  the  absolute  freedom  from  specific  dis- 
eases, should  they  be  allowed  to  perform  ritual  circumcision. 

As  another  reliable  measure  against  the  possibility  of  inoculating 
the  child,  when  the  parents  insist  upon  the  orthodox  method  of 
circumcision,  is  the  suction  by  the  aid  of  a  glass  tube,  as  practised 
in  France  and  Germany. 

CHAPTEE  X. 

What  Othek  Forms  of  Tuberculosis  Exist,  and  What  are 
Their  Principal  Symptoms  ? 

In  the  foregoing  chapters  we  have  treated  of  the  bacillus  of 
tuberculosis,  its  mode  of  entrance  into  the  system,  and  of  the 
symptoms  of  the  most  frequent  form  of  the  disease — that  is  to  say, 
consumption  or  pulmonary  tuberculosis.  Now  we  will  consider 
some  of  its  other  forms  or  manifestations. 


AND  HOW  TO  COMBAT  IT. 


29 


More  closely  related  to  consumption  than  any  other  form  of 
tuberculosis  is  laryngeal  tuberculosis,  also  called  tuberculosis  of 
the  larynx,  or  tuberculosis  of  the  throat.  This  disease  is  not 
nearly  so  frequent  as  pulmonary  tuberculosis,  but  sometimes  oc- 
curs with  it.  Besides  all  the  symptoms  which  tuberculosis  of 
the  throat  has  in  common  with  tuberculosis  of  the  lungs,  such  as 
fever,  nightsweats,  emaciation  or  loss  of  flesh,  difficulty  in  breath- 
ing, cough,  etc.,  there  are  in  this  disease  additional  symptoms, 
such  as  more  or  less  pronounced  hoarseness  and  frequent  and 
intense  pain  during  the  act  of  swallowing,  which  makes  eating 
bread,  meat,  and  other  solid  food  exceedingly  difficult.  The  inter- 
nal appearance  of  the  throat  shows  little  tuberculous  growths  and 
ulcers  in  the  region  of  the  vocal  cords  and  neighboring  tissue. 
•  Tuberculosis  of  the  bones,  which  not  infrequently  leads  to  a 
total  necrosis — ^that  is,  a  softening  and  final  decay  of  the  bones — is 
not  a  rare  disease.  If  the  seat  of  the  disease  is  the  spinal  column, 
the  decay  of  one  or  more  vertebrae  may  result  in  the  deformity 
commonly  known  as  hunchback.  If  through  this  breaking  down 
there  should  result  a  compression  of  the  spinal  marrow,  paralysis 
of  arms  or  legs,  and  other  distiubances,  such  as  difficulty  in  retain- 
ing the  uime  and  the  stools,  may  be  observed. 

While  tuberculosis  of  the  bones  and  joints  is  almost  painless  at 
the  beginning,  it  may  gradually  lead  to  loss  of  the  use  of  the  joints, 
to  maturation  and  destruction,  which  may  become  extensive 
enough  to  make  even  amputation  necessary. 

In  younger  children  tuberculous  spinal  meningitis  is  not  rare, 
and,  alas !  very  often  proves  fatal.  The  essential  symptoms  of  this 
disease  are  digestive  disturbances  (vomiting  or  constipation), 
uneasiness  and  depression,  later  on  paralysis  of  the  extremities, 
delirium,  and  sometimes  coma  (profound  insensibility). 

More  frequent  and  almost  as  dangerous  as  tuberculous  menin- 
gitis in  children,  is  tuberculosis  of  the  intestines  and  the  perito- 
neum (the  lining  of  the  abdominal  cavity).  This  affection  is 
sometimes  also  called  consumption  of  the  bowels.  The  most  pro- 
nounced symptom  in  such  cases  is  very  often  a  protracted 
diarrhoea,  which  cannot  be  easily  controlled  by  dieting  or  medica- 
tion. 


Tuberculo- 
sis of  the 
Throat. 


Tuberculo- 
sis of  the 
Bones. 


Tubercu- 
lous 
Meningitis. 


Consump- 
tion of  the 
Bowels. 


30 


TUBERCULOSIS   AS   A  DISEASE   OF  THE   MASSES 


At  times  the  whole  body  is  invaded  by  the  tuberculous  disease, 
and  countless  little  tubercles  are  distributed  in  all  the  organs. 
This  disease  is  then  called  "  miliary  tuberculosis  "  because  the  tu- 
bercles are  like  millet  seeds.  The  orighi  of  this  disease  is  probably 
always  due  to  the  sudden  outbreak  of  a  localized  tuberculous  lesion, 
which  had  been  at  a  standstill  before.  The  first  symptoms  of  mil- 
iary tuberculosis  resemble  those  of  typhoid  fever.  They  are  gen- 
erally depression,  lassitude,  and  fever.  This  is  also  one  of  the 
forms  of  tuberculosis  which  often  prove  fatal. 

Of  the  so-called  localized  tuberculous  diseases,  we  must  mention 
the  form  which  manifests  itself  as  a  skin  disease  and  is  known  as 
lupus,  showing  itself  as  ulcerous  patches  mainly  on  the  face. 

So-caUed  scrofulosis,  or  scrofula,  is  now  considered  also  as  a 
form  of  tuberculosis.  It  appears  almost  exclusively  during  child- 
hood. It  is  a  milder  disease  than  the  other  forms  of  tuberculosis, 
and  manifests  itself  mainly  in  swelling  of  the  glands,  eruption  of 
the  skin,  and  inflammation  of  eyes  and  ears. 

CHAPTER   XL 


What  Pkotects  the  Healthy  Individual  feom  Contracting 

Tuberculosis  ? 

After  all  that  we  have  said  of  the  contagiousness,  or  rather  the 
communicability,  of  tuberculosis,  and  consumption  in  particular, 
one  must  not  think  that  a  l^reath  in  an  atmosphere  accidentally 
laden  with  bacilli  would  certainly  render  a  healthy  individual 
consumptive,  or  that  by  a  swallow  of  tuberculous  milk  or  a  lit- 
tle injury  from  a  broken  cuspidor  one  must  necessarily  become 
tuberculous.  The  secretions  of  our  nasal  cavities,  doul)tlessly  also 
the  blood,  and  the  secretions  of  the  stomach  <tf  a  liealthy  individ- 
ual, have  Ijactericidal  properties;  that  is  to  say,  they  kill  the  dan- 
gerous germs  before  they  have  a  chance  to  do  harm.  Therefore, 
the  healthy  man  and  woman  should  not  have  an  exaggerated  fear  of 
tuberculosis,  but  they  should,  nevertheless,  not  recklessly  expose 
themselves  to  the  danger  of  infection. 


AND   HOW  TO   COMBAT  IT. 


31 


CHAPTEE   XIL 

How   MAY  One   Successfully    Overcome  a  Hereditary  Dis- 
position TO  Consumption  ? 

The  mother  who  fears  for  lier  future  child  a  hereditary  dispo- 
sition to  tuberculosis  should  lead  a  very  healthful  life.  She  should 
be  as  much  in  the  open  air  as  possible,  breathe  deeply  and  eat 
regularly  of  plain  but  nourishing  food.  Never  should  she  wear 
garments  which  constrict  any  of  her  chest  or  abdominal  organs. 
She  should  replace  the  corset  by  a  comfortable  waist  which 
permits  fi^ee  and  deep  respiratory  movements.  Instead  of  tying 
her  skhts  around  her  waist,  she  should  have  them  suspended  from 
the  shoulders,  which  can  easily  be  done  by  attaching  buttons  to 
the  waist.  By  wearing  a  close-fitting  imion  suit  for  underwear,  of 
wool  or  cotton  according  to  the  season,  it  will  be  possible  to  get 
along  with  less  skii'ts,  and  thus  lessen  the  weight  around  the  waist. 
The  whole  -dress  of  the  mother  should  be  so  arranged  that  there  are 
no  constricting  bands,  and  that  no  organ  in  the  body  should  be 
hindered  in  its  free  physiological  functions.  How  important  a 
more  healthful  and  natural  dress  really  is  for  the  welfare  and  de- 
velopment of  mankind  in  general,  a  mother  seldom  realizes  either 
for  herself  or  for  her  daughters.  They  are  all  only  too  often  the 
slaves  of  fashion.  The  tightly  laced  corset  should  be  banished 
forever  from  the  dress  of  women.  Not  only  is  free  and  natural 
breathing  interfered  with  by  this  article  of  dress,  but  indiges- 
tion and  distm-bances  in  the  circulation  follow  excessively  tight 
lacing.  Anaemia,  or  poverty  of  the  blood,  so  often  observed  in 
young  girls,  can  very  frequently  be  ascribed  to  this  unnatural 
mode  of  dress,  which  does  not  permit  either  a  fi-ee  ch-culation  or 
sufficient  oxygenation  of  the  blood. 

We  reproduce  here  three  pictures  better  to  illustrate  the  result 
of  excessive  lacing.  Fig.  11  shows  the  situation  of  the  organs  in 
chest  and  abdomen  in  a  normal  thorax.  Fig.  12  shows  lungs, 
heart,  and  intestines  as  they  appear  in  a  thorax  constricted  by 
(vearing  a  tightly  laced  corset  for  a  number  of  years.  Fig.  13 
shows  the  skeleton  of  a  chest  deformed  by  tight  lacing. 


Hygiene 

and  Dress 
for 

Tubercu- 
lous 

Mother«. 


Tight 
Lacing. 


32 


TUBERCULOSIS  AS  A  DISEASE   OF  THE   MASSES 


Belts.  The  wearing  by  men  of  belts  instead  of  suspenders  is  not  to  be 

recommended.  In  order  to  keep  the  trousers  in  place  the  belt 
must  be  considerably  tightened,  the  result  is  constriction  of  the 
abdomen,  hindering  the  natural  action  of  the  intestines  which  is 
essential  to  good  digestion.  Hernias  (ruptures)  may  also  be  the 
result  of  this  mode  of  dress.  It  cannot  be  insisted  upon  too  often 
that  in  an  individual  predisposed  to  tuberculosis  nothing  can  b^. 
more  injurious  than  an  interference  with  proper  digestion  and  as- 
similation. To  keep  stomach  and  bowels  in  good  order  is  one  of 
the  best  safeguards  against  taking  the  disease. 

Neckwear,  for   men    as  well  as  for  women,  should  be   loose. 
Tight  and  constricting  collars  or  bands  around  the  neck  may  cause 


FIG.  11. 


Fig.  12. 


FIG.  13. 


an  insufficient  air-supply,  congestion  of  the  arteries  of  the  brain. 
Neckwear,  and  subsequently  headache  and  dizziness.  To  dress  the  neck  too 
warmly  lessens  the  power  to  resist  taking  cold  when  there  happens 
to  be  a  change  in  the  atmosphere.  The  less  one  is  accustomed  to 
bundling  up  the  neck,  the  less  liable  wiD.  he  be  to  take  cold. 

Ladies  cannot  be  told  too  often  to  abandon  the  unhygienic  fash- 
ion of  trailing  dresses,  at  least  in  the  street.  They  should  De 
brave  and  show  the  world  that  they  care  for  the  health  and  wel- 
fare of  others.  When  one  considers  how  many  millions  of  dan- 
gerous bacilli  and  micro-organisms  are  gathered  up  with  the  dust 
and  brought  into  the  house  by  this  unhealthy  mode  of  dress,  further 
argument  is  hardly  necessary  to  prove  that  the  wearing  of  trains 
is  absolutely  dangerous  to  health.    Aa  the  poet  of  the  London  Truth 


Trailing 
Skirts. 


AND  HOW  TO   COMBAT  IT.  33 

puts  it  in  his  "  Song  of  the  Skirt,"  why  should  dresses  be  made  to 
do  "the  scavenger's  dhty  "work  ": 

**  Sweep — sweep— sweep — 
Where  the  waste  of  the  street  lies  thick, 
Sweep— sweep — sweep — 
However  our  path  we  pick ; 
Dust,  bacillus,  and  germ, 
Germ,  bacillus,  and  dust, 
Till  we  shudder  and  turn  from  the  sorry  sight 
With  a  gesture  of  disgust. 

"Oh,  men  with  sisters  dear  ! 
Oh,  men  who  have  well-dressed  wives, 
It  is  not  alone  an  expensive  mode. 
It  is  one  that  hazards  lives  ! 
For  malignant  microbes  swarm 
In  the  triturated  dirt, 
And  the  dress  that  sweeps  it  up  may  prove 
A  shroud  as  well  as  a  skirt !  " 

Footwear  is  also  a  matter  of  importance.     Shoes  should  never 
be  worn  too  tight.     They  not  only  hinder  free  movements,  but  the    Footwear. 
constriction  of  the  blood-vessels  causes  impaired  circulation  and 
coldness  of  the  extremities. 

If  it  is  found  necessary  to  wear  underwear  at  night,  a  different 
set  should  be  kept  for  that  purpose,  which,  with  the  night-dress  or 
night-shirt,  should  be  well  aired  during  the  day-time. 

Whenever  a  mother  has  a  tendency  to  tuberculous  disease,  the      Hygiene 

child  should  be  given  a  healthy  wet-nurse,  or  be  fed  artificially  and  Care  of 

with  modified  cow's  milk.     The  advice  of  the  physician  is  iridis-       ®    ,       ° 

pensable  under  such  circumstances.      The  child  should  have  its         Iqus 

own  bed,  and  should  never,  never  sleep  in  the  same  bed  with  the      Mother. 

mother.     The  bedroom  should  always  be  well  ventilated,  and  the 

child  should  be  taken  into  the  open  air  as  soon  as  practicable. 

The  old-fashioned  habit  of  enveloping  the  child's  head  in  a  thick 

veil  should  be  abandoned.     It  is  a  good  plan  to  let  the  little  one 

run  about  naked  or  with  only  a  little  shirt  on,  for  a  while  every     .  !'^^^, 

„    Air  Baths 
day  in  a  warm,  sunny  room.     A  bare  wooden  floor  or  a  square  of     ^^j.  j^jt^le 

closely  woven  matting,  that  can  be  kept  scrupulously  clean,  is     Children. 

much  to  be  preferred  to  dust-collecting  carpets. 

From  the  tenth  to  the  twelfth  month  one  should  accustom  the 

3 


34  TUBERCULOSIS  AS   A  DISEASE   OF  THE  MASSES 

child  gradually  to  cold  baths.  The  best  way  to  begin  is  after  its 
H  f  Cold  daily  warm  bath  to  rub  the  child  a  few  times  with  the  hands 
Water.  dipped  in  cold  water,  and  then  wipe  it  rapidly.  By  and  by  one 
may  begin  with  cold  sponging,  and  later  on  with  a  little  douche. 
In  the  use  of  cold  water  it  is  absolutely  necessary  that  th.e  reaction 
should  rapidly  follow.  This  reaction  is  manifested  by  a  pleasant 
warmth  perceived  by  the  chüd,  and  externally  is  made  visible  by 
a  reddish  appearance  of  the  skin.  Whenever  cold  water  is  applied 
to  the  skin  one  will  notice  at  first  a  eertaia  whiteness  or  paUor, 
which  is  caused  by  a  contraction  of  the  external  blood-vessels. 
The  retiun  of  the  blood  to  the  external  surface  causes  the  redden- 
ing of  the  skin.  Whenever  reaction  is  lacking  or  tardy,  the 
advice  of  the  physician  should  be  sought. 

Though  the  application  of  cold  water  is  beneficial,  one  should 
never  forget  that  there  are  people  whose  constitutions  difier,  and 
that  a  routine  treatment  is  not  applicable  to  every  individual. 
The  careful,  judicious,  and  regular  application  of  cold  water  is 
perhaps  one  of  the  best  preventive  measures  against  taking  cold, 
for  children  as  well  as  adults,  and  its  use  generally  should  be  more 
recommended.  Persons  not  accustomed  to  the  use  of  cold  water 
can  easily  become  so  by  being  rubbed  every  day  with  alcohol 
for  a  week  or  so.  During  the  second  week  they  should  be  rubbed 
with  half  alcohol  and  half  water,  and  the  third  week  with  water 
alone.  By  this  means  one  gi-adually  educates  one's  self  to  the  use 
of  cold  sponge  baths,  ablutions,  and  douches. 

Every  family  does  not  have  the  luxury  of  a  douche  apparatus. 
Improvised  ^^^  sometimes  not  even  a  bathroom.  For  such  I  wish  to  describe 
Douche.  a  simple  metliod  which  wiU.  answer  the  purpose.  Take  a  large 
chcular  English  bath-tub,  about  three  feet  in  diameter  and  ten 
inches  high,  and  pour  about  five  inches  of  cold  or  tepid  water  into 
it.  The  bather  jumps  into  the  water,  keeping  his  feet  in  motion 
for  a  few  seconds,  and  pours  one  or  two  pitcherfuls  of  water  quick- 
ly over  each  shoiüder,  thoroughly  wetting  the  whole  body.  It  is 
not  at  all  essential  that  the  head  should  be  wet  at  the  same  time. 
The  douche  can  be  made  easier  by  the  help  of  a  second  person  to 
pour  the  water  from  the  i)itcher  or  watering-pot.  If  a  hose  can  be 
attached  to  a  nearby  faucet,  a  douche,  needle  bath,  or  direct  jet 


AND   HOW   TO   COMBAT   IT. 


35 


can  be  improvised.  The  temperature  of  the  water  may  vary  from 
60°  to  40°  r.  The  room  in  which  the  bath  is  taken  should  be 
warmed  in  cold  weather.  The  best  and,  perhaps,  also  most  con- 
venient time  to  take  a  cold  bath  is  in  the  morning  before  dressing, 
or  in  the  evening  before  retiring.  Whenever  reaction  is  feeble, 
that  is  to  say,  when  a  pleasant  feeling  of  warmth  after  the  bath 
does  not  come  quickly  enough,  one  should  proceed  as  follows :  If 
the  bath  is  to  be  taken  in  the  morning  rise  half  an  hour  earlier, 
cover  the  bed  so  that  the  warmth  is  retained ;  then,  after  the  ap- 
plication of  cold  water  has  been  taken  rapidly  in  the  manner 
above  described,  rub  with  a  rough  Turkish  towel  and  retm-n  as 
quickly  as  possible  to  the  warm  bed.  If  it  is  not  practicable  to 
take  the  bath  in  the  morning,  one  can  obtain  the  same  result  by 
going  to  bed  half  an  hour  earlier,  and  when  the  bed  is  warm  rise 
again  to  take  the  cold-water  application.  In  most  cases  the  return 
to  the  warm  bed  will  assure  a  thorough  reaction ;  but  if  these  pre- 
cautions, in  addition  to  vigorous  friction  after  the  bath,  do  not 
suffice  to  produce  a  proper  reaction,  it  is  a  sign  that  the  body  has 
not  enough  resistance  for  this  kind  of  treatment,  and  the  physician 
should  be  consulted. 

Cold  baths,  especially  bathing  in  a  river  or  in  the  ocean,  are,  of 
course,  to  be  recommended  in  warm  weather.  Weakly  and  elderly 
persons  should  not  take  cold  baths,  no  matter  at  what  season,  im- 
less  permitted  to  do  so  by  their  physician. 

To  keep  the  skin  clean  and  in  good  condition,  cold  baths,  even 
when  taken  every  day,  are  not  always  sufficient,  and  soap  and 
warm  water  should  be  used  at  least  once  a  week.  The  warm  bath 
should  always  be  followed  by  a  rapid  sponging  off  with  cold  water. 

As  soon  as  the  intelligence  of  the  growing  child  will  permit,  it 
should  be  taught  to  breathe  deeply,  and  later  on  be  taught  to  take 
the  following  breathing  exercises,  which  the  child  should  learn  to 
love  as  the  average  boy  or  girl  loves  general  gymnastics.  In  front 
of  the  open  window  or  out  of  doors  assume  the  position  of  the 
military  "attention,"  heels  together,  body  erect,  and  hands  on  the 
sides.  With  the  mouth  closed  take  a  deep  inspnation  (that  is, 
breathe  in  all  the  air  possible),  and  while  doing  so  raise  the  arms 
to  a  horizontal  position ;   remain  thus  holding  the  air  inhaled  for 


How  to 

Help 
Reaction. 


■Warm 
Saths. 


Respira- 
tory 

Exercises 

with 
Movement 

of  Arms. 


36 


TUBERCULOSIS  AS   A  DISEASE   OF   THE   MASSES 


about  three  seconds,  and  while  exhaling  (breathing  out)  bring  the 
arms  down  to  the  original  position.  This  act  of  exhalation,  or 
expiration,  should  be  a  little  more  rapid  than  the  act  of  inspiration. 

When  the  first  ex- 
ercise is  thorough- 
ly mastered  and 
has  been  prac- 
tised for  several 
days,  one  may 
begin  with  the 
second  exercise, 
which  is  like  the 
first,  except  that 
the  upward  move- 
ment of  the  arms 
is  continued  until 
the  hands  meet 
over  the  head. 

The  a  c  c  o  m  - 
panying  illustra- 
tion  (Fig.  14) 
shows  the  posi- 
tions which  are  to 
be  taken  during 
those  two  exer- 
cises. The  third  breathing  or  respii^atory  exercise,  which  requii*es 
more  strength  and  endurance,  should  not  be  undertaken  until  the 
first  two  have  been  practised  regularly  several  times  a  day  for  a  few 
weeks,  and  until  an  evident  improvement  in  breathing  and  general 
well-being  has  been  observed.  We  will  endeavor  to  make  this  third 
exercise,  whicli  might  l)e  called  a  dry  swim,  more  comprehensible 
by  the  illustration  (Fig.  15).  Take  the  same  military  position  of 
"attention,"  and  then  stretch  the  arms  out  as  in  the  act  of  swim- 
ming, tlie  backs  of  the  hands  touching  each  other.  During  the  in- 
spiration move  the  arms  outward  until  they  finally  meet  behind  the 
back.  Remain  in  this  position  a  few  seconds,  retain  the  air,  and 
during  exhalation  bring  the  arms  forward  again.     This  somewhat 


Fig.  14.— First  and  Second  Breathing  Exercises. 


AND   HOW   TO   COMBAT   IT. 


37 


difficult  exercise  can  be  facilitated  and  be  made  more  effective  by 
rising  on  the  toes  during  the  act  of  inhalation,  and  descending 
during  the  act  of  expiration. 

Of  course,  when  out  of  doors  one  cannot  always  take  these  ex- 
ercises with  the  movement  of  the  arms  without  attracting  atten- 
tion: under  such  conditions  raise  the  shoulders,  making  a  rotary 
backward  movement  during  the  act  of  inhaling;  remain  in  this 
position,  holding  the  breath  for  a  few  seconds,  and  then  exhale 
while  moving  the  shoulders  forward  and  downward,  assuming  again 
the  normal  position.  This  exercise  (Fig.  16)  can  be  easily  taken 
while  walking,  sitting,  or  riding 
in  the  open  air. 

Young  girls  and  boys,  and  es- 
pecially those  who  are  predisposed 
to  consumption,  often  acquire  a 
habit  of  stooping.  To  overcome 
this  the  following  exercise  (Fig. 
17)  is  to  be  recommended.  The 
child  makes  his  best  effort  to 
stand  straight,  places  his  hands 
on  his  hips  with  the  thumbs  in 
front,  and  then  bends  slowly 
backward  as  far  as  he  can  during 
the  act  of  inhaling.  He  remains 
in  this  position  for  a  few  seconds, 
while  holding  the  breath,  and  then 
rises  again  somewhat  more  rapid- 
ly, during  the  act  of  exhalation. 

The  following  general  rule  con- 
cerning breathing  exercises  should 
always  be  remembered.  Com- 
mence with  the  easier  exercises 
(Figs.  14  and  16),  and  do  not  begin  with  the  more  difficult  ones  (Figs. 
15  and  17)  until  the  former  are  completely  mastered.  Take  from 
three  to  six  respiratory  exercises,  either  of  one  kind  or  the  other, 
every  half  hour,  and  continue  this  practice  until  deep  breathing  has 
beqome  a  natural  habit.     These  exercises  should  always  be  taken  in 


FIG.  15.— Third  Breathing  Exercise. 


Respira- 
tory 
Exercises 
without 
Movement 
of  Arms. 


General 
Rules 
Concerning 
Respira- 
tory 
Hxerciseg. 


38 


TUBERCULOSIS   AS   A  DISEASE   OF  THE   MASSES 


) 


/' 


an  atmosphere  as  fresh,  and  as  free  from  dust  as  possible.  Never 
take  these  exercises  when  thed,  and  never  continue  so  long  as  to 
become  tii'ed. 

Mouth-breathing  in  children,  and  sometimes  in  adults,  is  often 
caused  by  certain  gi'owths  in  the  throat  (adenoid  vegetation),  by 
enlarged  tonsils,  or  by  growths  in  the  nose  (polypi,  etc.)  The  re- 
moval   of    these 

obstructions     by 

surgical    aid    is 

perhaps  the  only 

rational    method 

to  assure  natural 

breathing.       In- 
cidentally,     w  e 

may  be   permit- 
ted  to   say  that 

these    operations 

are   not    at    all 

dangerous ;     but 

by  the  presence 

of  these  vegeta- 

t  i  o  n  s    in     the 

throat    (retro- 

pharynx)       the 

hearing  and  the 

intellectual    and 

bodily      develop-    fig.  17.— Exercise  for  People  in  the 
"^  Habit  of  Stooping. 

ment  of  the  child 
may  become  seriously  impaired.  The  early  removal  of  such  growths 
should  be  earnestly  recommended.  The  respiratory  exercises  just 
described  are  particularly  useful  for  such  children  after  operation, 
otherwise  they  might  retain  the  habit  of  imperfect  breathing  which 
they  had  acquhed. 

Among  exercises  which  have  a  tendency  to  develop  and 
strengthen  lungs  and  throat,  we  will  also  mention  singing  and  re- 
citing ill  the  open  ah. 

Not  only  dm-ing  the  day,  but  also  at  night,  there  should  be  9, 


Fig.    16.  —  Breathing   Exercise 
with  Rolling  of  Shoulders. 


AND   HOW   TO   COMBAT   IT. 


39 


HUMIDIFIER       ^ 

1  FLOOP  DEOISTER 

2  WATER  TANK     \ 

3  SHEETS  OF 

COTTON  FrLT.-' 


desii-e  for  fresh  air.  The  still  very  prevalent  idea  that  night  air  is 
injurious  is  wrong.  The  night  air  is  purer  than  that  of  the  day, 
particularly  in  great  cities,  therefore  one  should  always  keep  at 
least  one  window  open  in  the  bedroom  or  in  an  adjoining  room, 
and  thus  assure  a  sufficient  and  permanent  ventilation.  Of  course, 
it  is  always  wise  to  protect  one's  seK  against  dkect  draughts  from 
the  open  window.  When  it  is  not  possible  to  place  the  bed  so 
that  it  will  be  out  of  the  draught,  a  screen  in  front  of  the  open 
window  wiR  suffice  for  protection. 

It  is,  of  com'se,  self -understood  that  all  individuals  who  have 
an  inherited  disposition  to  tuberculosis  should  always  endeavor  to 
live  as  much  as  pos- 
sible in  good,  fresh, 
pure  air.  To  visit 
dancing-halls,  saloons, 
and  smoking-rooms 
can  only  be  deleterious 
to  such  people.  Smok- 
mg  should  be  abso- 
lutely prohibited  for 
young  men  with  weak 
chests,  and  for  all  peo- 
ple having  a  tendency 
to  tuberculosis.  The 
smoking  of  cigarettes  is  particularly  dangerous,  since  the  habit  once 
acquired  tends  to  undermine  even  a  strong  constitution. 

Many  of  our  American  dwellmgs  in  winter  are  heated  altogether 
too  much.  A  temperature  of  from  65°  F.  to  68°  F,  should  be  suf- 
ficient, especially  when  care  is  taken  that  the  heat  produced  by 
the  furnace  is  not  too  dry.  The  excessively  dry  atmosphere  in 
whiter  of  many  city  and  country  homes  often  gives  rise  to  nasal 
catan-h,  a  condition  which  everybody,  but  especially  those  suffer- 
ing from  pulmonary  diseases,  or  prone  to  them,  should  be  anxious 
to  avoid.  Besides  keeping  the  water  pan  in  the  furnace  con- 
stantly filled,  there  should  be  in  the  sitting-room  and  sleeping- 
rooms  some  humidifying  arrangement  such  as  is  pictured  here 
(Fig.  18).     More  simple  evaporating  devices,  however,  as  a  vessel 


Fig.  18.— Humidifler. 


Relative 

Purity  of 

Night  Air, 


Crowded 

Rooms  and 

Smoking. 


Excessive 
Dryness 
and  Heat 

in 
Dwellings. 


40  TUBERCULOSIS   AS  A  DISEASE   OF  THE  MASSES 

filled  with,  water  and  a  cloth  suspended  above  it  touching  the 
water  so  as  to  produce  capillary  attraction,  will  answer  the  purpose 
of  rendering  the  atmosphere  sufficiently  humid. 

The  proper  bringing  up  of  children  that  have  a  tendency  to  become 
tuberculous  is  of  the  greatest  importance.     Many  are  poor  eaters 
Raisings      from  the  day  of  their  birth.     Discipline,  not  to  allow  too  many 
Educating"     ^^^^ts,  to  observe  regular  meal- times  and  to  keep  the  bowels  in  good 
Predisposed  condition,  are  the  best  means  to  combat  a  dislike  for  eating.     As 
Children,     early  as  possible  children  should  be  taught  to  clean  their  teeth 
thoroughly  after  each  meal,  for  a  good  digestion  is  dependent  upon 
the  condition  of  the  teeth.     The  dislike  to  play  outdoors,  which  is 
so  characteristic  of  the  little  candidates  for  tuberculous  diseases, 
can  also   only  be  overcome   by  discipline.     To  dress   them  too 
warmly  and  bundle  them  up  all  the  time  is  as  injurious  as  having 
them  remain  most  of  the  time  indoors.     Such  children  should  not 
work  too  hard  during  their  school  age.     To  spend  too  many  hours 
sitting  down,  to  do  too  much  brain  work,  to  spend  too  much  time 
at  the  piano  or  in  other  musical  studies,  have  a  tendency  often  to 
weaken  seriously  the  child  predisposed  to  tuberculosis. 
y^  J  Gymnastic  exercises  should  be  recommended  to  young  people 
-  dJ''  "BötH  sex#:,^and  young  girls  especially  should  continue  their 
healthful  outdoor  sports  after  they  have  left  school.     Of  course, 
excesses  are  injurious  in  everything,  and  we  wish  to  say  here  that, 
no  matter  how  healthful  a  sport  may  be,  if  carried  on  too  violently 
or  for  too  long,  it  must  ultimately  prove  injurious.     To  be  cheerful, 
to  live  a  regular  life,  to  eat  plain  but  good  food,  to  avoid  all  alco- 
holic beverages,  to  see  that  the  bowels  move  freely  every  day,  to 
keep  the  whole  body  clean,  and  to  sleep  at  least  eight  hours  out  of 
twenty-four,  is  the  best  way  to  remain  well. 

Once  more  we  desire  to  call  attention  to  the  clothing  of  growing 
girls  and  boys.  The  thickness  of  the  garments  should  be  accord- 
ing to  the  season,  and  they  should  always  be  made  so  that  every 
movement  of  the  body  may  be  free,  and  none  of  its  fimctions,  such 
as  respiration,  digestion,  etc.,  in  any  way  interfered  with. 

When  the  time  comes  to  choose  a  profession  or  trade  for  a  young 

Choice  of     man  who  has  a  tendency  to  tuberculosis,  one  should  bear  in  mind 

Occupation.    ^^^^^  gardening,  farming,  forestry,  and  all  occupations  which  de- 


AND   HOW   TO   COMBAT   IT.  41 

mand  an  outdoor  life,  are  the  most  likely  to  make  him  a  strong 
man  and  a  useful  member  of  society. 

In  connection  with  the  precautions  which  should  be  taken  to 
combat  a  tendency  to  tuberculosis,  we  must  say  a  few  words  con- 
cerning the  curability  of  consumption  or  pulmonary  tuberculosis.   Hereditary 
The  old  idea — still,  alas !  very  prevalent  and  deeply  rooted  in  the     Consump- 

minds  of  many  people — that  a  tuberculous  individual  who  has  seem-    f.      , , 

•'  J-     ^  Curable  as 

ingly  mherited  his  tendency  to  the  disease,  can  have  no  hope  of  Acquired 
ciu-e,  is  wrong.  We  desire  to  emphasize  the  fact  that  the  chances  Consump- 
for  a  cm'e  of  the  consumptive  individual  does  not  at  all  depend  ^°^' 

upon  whether  he  had  a  hereditary  tendency,  or  has  accidentally 
acquired  the  disease.  There  are  hundreds  of  cases  of  healed  tuber- 
culosis in  men  and  women  who  have  lived  to  old  age,  and  never- 
theless their  fathers  or  mothers  had  succumbed  to  consumption. 

The  assumption  that  tuberculosis  is  often  directly  transmitted 
from  parent  to  child  is  equally  erroneous.  Of  course,  there  are  in  Hereditary 
medical  literature  a  few  cases  which  show  that  such  direct  trans-  Transmis- 
mission  is  possible,  but  they  are  exceedingly  rare.  Wlien  little 
children  have  become  tuberculous  the  infection  can  almost  always 
be  traced  to  the  child  having  slept  or  been  much  in  contact  with 
a  consumptive  mother  or  other  consumptive  individuals,  having 
been  kissed  on  the  mouth,  or  having  played  on  the  dhty,  infected 
floor,  etc.  All  this  shows  the  importance  of  absolute  cleanliness 
and  the  strictest  hygiene  from  early  infancy. 

CHAPTER   XIII. 

How  CAN  A  Predisposition  to  Tuberculosis,  Other  than 
Hereditary,  be  Created  or  Acquired? 

1.  By  the  intemperate  use  of  alcoholic  beverages,  a  dissipated 
life,  excesses  of  all  kinds,  etc. 

2.  By  certain  diseases  which  weaken  the  constitution ;  for  ex- 
ample, pneumonia,  typhoid  fever,  smallpox,  measles,  whooping 
cough,  syphilis,  influenza,  etc. 

3.  By  certain  occupations,  trades,  and  professions,  such  as  print- 
ing, hat-making,  tailoring,  weaving,  and  all  occupations  where  the 
worker  is  much  exposed  to  the  inhalation  of  various  kinds  of  dust, 


42 


TUBERCULOSIS   AS   A  DISEASE   OP   THE   MASSES 


as  bakers,  millers,  confectioners,  cigar-makers,  chimney-sweepers, 
and  the  workers  in  lead,  wood,  stone,  metals,  etc. 


Tuberculo- 
sis and 
Venereal 
Diseases. 


Hygiene  in 

Factories, 

Workshops, 

etc. 


CHAPTER   XIV. 

How  MAY  AN  Acquired  Predisposition  be  Overcome,  and 
Seemingly  Unhealthy  Occupations  Made  Eelatively 
Harmless  ? 

All  persons  who  have  been  weakened  through  intemperance  or 
excesses,  who  are  convalescent  from  serious  diseases,  or  who  are  suf- 
fering from  the  effects  of  harmful  occupations,  should  not  associate 
with  consumptives.  For  the  intemperate  man,  the  fast  liver,  or 
one  inclined  to  excesses,  there  is  no  remedy  except  to  change  his 
mode  of  life.  The  unfortunate  who  by  his  own  fault  or  the  care- 
lessness of  others  has  fallen  a  victim  to  a  venereal  disease  (syphilis, 
etc.)  we  would  urgently  recommend  to  submit  himseK  to  thorough 
treatment  by  a  competent  physician.  For  the  comfort  of  these 
imfortunate  sufferers,  we  desire  to  say  that  all  venereal  diseases  can 
be  successfully  treated  when  the  patient  seeks  timely  medical  ad- 
vice and  obeys  the  physician's  instructions  faithfully.  Since  ven- 
ereal diseases  are  highly  contagious,  the  physician's  instructions 
will  also  protect  others  from  becoming  mfected,  and  the  patient 
himself  from  reinfection.  The  necessity  of  seeking  medical  advice 
holds  good  for  all  those  who  by  intemperance  or  excesses  of  any 
kind  have  undermined  then-  constitution,  and  thus  diminished  their 
natural  resistance  to  the  invasion  of  the  tubercle  bacilli. 

In  many  States  of  the  Union  there  now  exist  laws  whereby  the 
sanitary  conditions  of  factories,  workshops,  department-stores,  etc., 
are  assured.  Of  course,  there  is  room  for  much  improvement  in 
this  respect,  especially  in  regard  to  light  and  sufficient  ventilation 
in  factories  where  dust  and  gases  are  a  constant  menace  to  the 
laborer.  Whenever  practicable,  resphatory  masks  for  protection 
against  particularly  irritating  dust,  should  be  worn.  People  much 
exposed  to  the  inhalation  of  flour  dust  should  clean  their  teeth 
thoroughly  (the  inside  as  well  as  the  outside).  By  removing  the 
flour  dust  from  the  spaces  between  the  teeth,  the  formation  of 
glucose  (sugar)  through  the  action  of  the  saliva  on  the  flour  is 


AND  HOW  TO  COMBAT  IT. 


43 


avoided,  and  thus  the  germs  of  fermentation  are  deprived  of  a 
favorable  soil  for  development. 

In  all  these  matters  the  laborer  can  help  himself  a  good  deal  by 
his  own  efforts  to  make  a  seemingly  dangerous  occupation  more  safe. 
During  the  hours  of  recess,  and  before  he  goes  to  work  as  well  as 
afterward,  he  should  always  strive  to  be  as  much  as  possible  in  the 
open  ail',  drink  plenty  of  pure,  clean  water,  keep  early  hours,  live 
as  regular  a  life  as  possible,  avoid  the  saloon,  and  never  take  alco- 
holic beverages. 

All  the  other  hygienic  precautions  and  means  of  improving  the 
general  health  of  which  we  have  spoken  in  Chapter  XII. ,  "  How 
may  one  successfully  overcome  a  hereditary  disposition  to  tuber- 
culosis? "  such  as  breathing  exercises,  the  use  of  cold  water,  etc., 
are,  of  course,  just  as  essential  to  combat  a  disposition  to  tuber- 
culosis which  has  been  acquired. 


CHAPTER   XV. 

What  can  Well-Meaning  and  Conscientious  Employers  in 
City  and  Country  Do  to  Help  Combat  Tuberculosis? 

All  who  employ  a  number  of  people  and  provide  their  lodgings 
should  bear  in  mind  that  unhealthy,  dark,  damp,  and  badly  venti- 
lated rooms  are  powerful  factors  in  the  propagation  of  tuberculosis. 
The  soil  upon  which  a  dwelling  for  human  beings  is  to  be  built, 
should  be  dry,  free  from  miasms  and  dangerous  exhalations.  High, 
porous  ground  is  particularly  to  be  recommended.  It  is  sometimes 
possible  to  render  a  damp  soil  healthful  by  thorough  drainage  and 
cementing.  The  house  should  always  be  built  of  good  material, 
and  all  the  rooms  should  receive  the  light  of  day  and  as  much 
sunshine  as  possible.  In  winter  the  rooms  should  be  well 
warmed,  but  not  overheated,  and  at  the  same  time  free  ventilation 
should  be  made  possible.  Bathrooms  in  sufficient  number  should 
be  in  all  model  tenement  houses,  and  each  family  should  have  its 
own  water-closet,  which,  of  course,  must  always  be  kept  in  good 
condition. 

In  labor  colonies  and  densely  populated  tenement  districts,  where 
ffiodern  bathing  facilities  cannot  be  easily  installed,  there  should 


44  TUBERCULOSIS  AS  A  DISEASE   OF  THE  MASSES 

be  public  places  where,  for  a  moderate  price,  people  can  enjoy  the 
Bathing  cleansing  and  refreshing  luxury  of  a  warm  or  cold  bath. 
Facilities.  In  factories,  workshops,  big  stores,  etc.,  there  should  always  be 
a  sufficient  number  of  spittoons,  preferably  elevated  and  of  un- 
breakable material.  Wlierever  such  precautions  are  taken  and 
some  conspicuous  signs,  forbidding  expectorating  on  the  floor,  put 
up,  and  if  necessary  making  it  punishable  by  law,  promiscuous 
spitting  will  soon  cease,  and  an  important  point  in  the  combat  of 
tuberculosis  will  be  gained. 

All  employees,  men  and  women  of  whatever  class,  should  be 
allowed  ample  and  regular  time  for  their  meals,  which  should 
never  be  taken  in  the  workshops.  Special  rooms  should  be  kept 
for  that  purpose.  Opportunity  should  be  given  to  the  workers  to 
Regularity  rest  or  walk  in  the  open  air  for  a  little  while  after  their  meal.  It 
01  Meals,  ^g  ^jg^  q£  importance  for  the  health  of  the  laborer  to  wash  his 
hands  thoroughly  before  touching  food,  and  proper  conveniences 
should  be  provided  for  that  purpose.  Factories,  workshops,  large 
stores,  etc.,  should,  of  course,  be  well  ventilated,  but  it  is  par- 
ticularly necessary  that  they  should  be  thoroughly  aired  after 
working  hours.  These  precautions  apply  not  only  to  large  estab- 
lishments, but  to  the  smallest  concern  with  one  or  two  employees 
as  well,  and  every  employer  should  bear  in  mind  that  a  healthy 
laborer  is  of  greater  value  than  one  who  is  overworked,  underfed, 
or  badly  housed.  Lastly,  employees  should  not  be  overworked. 
uverwor  ,  rpj^^j^^  should  be  reasonable  hours  for  all,  so  that  the  laborer  may 
enjoy  the  bodily  and  mental  rest  which  is  essential  to  the  preser- 
vation of  health.  The  germs  of  any  disease,  but  particularly  those 
of  tuberculosis,  will  always  find  a  more  congenial  soil  for  develop- 
ment in  an  overworked  and  enfeebled  system.  Child-labor,  that 
is  to  say,  the  employment  of  children  under  fourteen  years  of  age, 
in  factories,  workshops,  mines,  etc.,  should  be  prohibited  by  law. 
Child-labor.  The  child  is  m(jre  susceptible  to  tuberculosis  than  the  adult, 
especially  when  its  delicate  gi'owing  organism  is  subject  to  con- 
tinued physical  strain. 


AND   HOW   TO   COMBAT  IT.  45 

CHAPTEE   XVI. 

What  can  the  Farmer  and  Dairyman  Do  to  Diminish  the 
Frequency  of  Tuberculosis  among  Animals,  and  Thus 
Indirectly  Stop  the  Propagation  of  the  Disease  among 
Men? 

The  farmer  or  dairyman  who  employs  help  should,  of  course,  be 
as  anxious  for  their  physical  welfare,  their  proper  housing  and 
proper  food,  as  the  employer  in  the  city.  The  dairyman  or  the 
farmer  who  keeps  cows,  should,  however,  be  particularly  desirous 
to  help  in  combating  tuberculosis  among  animals. 

Everybody  who  has  anything  to  do  with  cows  should  be  ac- 
quainted with  the  nature  of  tuberculosis  in  cattle,  also  known 
by  the  name  "  bovine  tuberculosis. "  In  animals  as  well  as  in  man 
the  direct  cause  of  this  disease  is  the  tubercle  baculus.  Bovine 
tuberculosis  is  prevalent  in  nearly  every  country.  The  symptoms 
of  the  disease  are  much  like  those  in  man.  They  begin  with  rela- 
tively slight  functional  disturbances.  The  way  the  germ  of  tuber- 
culosis is  transmitted  from  animals  to  men,  and  also  from  men 
to  animals,  has  already  been  explained.  The  contagion,  or  rather 
the  propagation,  of  the  disease  among  animals  takes  place  in  vari- 
ous ways :  First,  by  drop  infection,  that  is  to  say,  little  particles 
which  are  expelled  during  the  seemingly  dry  cough.  Secondly, 
by  the  discharge  from  the  lungs,  or  also  from  the  glands  of  the 
tlnoat,  coughed  up  in  the  ordinary  way.  Thirdly,  through  tuber- 
culous matter  coming  from  the  bowels.  Fourthly,  through  secre- 
tions coming  from  the  sexual  organs  (vagina  and  uterus).  Fifthly, 
through  the  mük  if  the  udder  is  tuberculous,  or  if  the  whole  body 
of  the  animal  is  invaded  by  the  disease.  Finally,  the  disease  may 
be  directly  transmitted  from  the  tuberculous  cow  to  the  calf. 

As  to  the  frequency  of  the  various  ways  in  which  the  contagion 
takes  place  and  the  best  methods  of  prevention,  the  author  does 
not  believe  that  he  can  do  better  than  to  copy  some  of  the  very 
"Practical  Suggestions  for  the  Suppression  and  Prevention  of  Bo- 
vine Tuberculosis,"  issued  by  Dr.  Theobald  Smith,  of  the  Bureau 
of  Animal  Industry  in  Washington : 


46 


TUBERCULOSIS  AS  A  DISEASE   OF  THE   MASSES 


Suppression 

and 
Prevention 
of  Bovine 
Tuberculo- 
sis, 


"Fully  nine-tenths  of  all  diseased  animals  examined  have  been 
infected  by  inhaling  the  tubercle  bacilli,  dried  or  suspended  in  the 
air. 

"  Fully  one-half  of  all  diseased  animals  examined  have  been  in- 
fected by  taking  tubercle  bacilli  into  the  body  with  the  food. 
This  implies  that  both  food  and  air  infection  are  recognizable  in  the 
same  animal  in  many  cases. 

"Animals  are  infected,  though  rarely,  during  copulation.  In 
such  cases  the  disease  starts  in  the  uterus  and  its  lymph  glands, 
or  in  the  sexual  organs  and  corresponding  lymph  glands  of  the 
bull. 

-"Perhaps  from  one  to  tvi^o  per  cent,  of  all  calves  of  advanced 
cases  are  born  infected.  Among  the  two  hundred  cases  of  tuber- 
culosis, including  all  ages,  which  have  been  examined  by  the 
writer,  there  are  about  two  per  cent,  in  which  the  disease  is  best 
explained  as  having  been  directly  transmitted  from  the  mother  dur- 
ing or  before  birth. 

"We  may  define  the  dangers  of  infection  somewhat  more  defi- 
nitely by  the  statement  that  iu  any  herd,  even  in  those  extensively 
infected,  only  a  small  percentage  of  the  diseased  animals,  namely, 
those  which  are  in  an  advanced  stage,  or  such  as  have  the  disease 
localized  from  the  very  beginniug  in  the  udder,  or  the  uterus,  or 
the  lungs,  are  actively  shedding  tubercle  bacilli.  It  is  these  that 
are  doing  most,  if  not  all,  of  the  damage  by  scattering  broadcast 
the  \arus. 

"Disease  of  the  udder  is  particularly  dangerous,  because  the 
milk  at  first  appears  normal  for  some  weeks,  and  therefore  would 
be  used  with  impunity.  Moreover,  the  tubercle  baculi  in  the  dis- 
eased gland  tissue  are  usually  numerous. 

"  Similarly,  in  tuberculosis  of  the  uterus  the  vaginal  discharges 
may  contain  many  tubercle  bacilli.  These  deposited  anywhere  may 
lead  to  the  extensive  dissemination  of  tlie  virus,  or  it  may  be  car- 
ried by  the  Ijull  to  other  cows.  A  diagnosis  may  be  made  by  the 
examination  of  any  existing  discharge  for  tubercle  baculi. 

"  The  foregoing  statements  apply  to  individual  herds  only.  To 
what  extent  does  the  danger  extend  beyond  the  diseased  herd  to 
others  in  the  neighborhood?     To  this  we  may  give  the  general 


AND   HOW  TO   COMBAT  IT.  47 

answer  that  there  is  no  danger  unless  the  animals  mingle  on  the 
pasture  or  in  the  stable.  Tubercle  bacilli  are  not  carried  in  the 
open  air,  or  if  they  are  their  numbers  are  so  small  that  the  danger 
of  infection  is  practically  absent. 

"It  is  also  highly  doubtful  whether  they  are  ever  carried  in 
sufficient  numbers  by  third  parties  from  place  to  place  to  become 
in  a  sense  a  danger.  The  reasons  for  this  must  be  sought  for  in 
the  tubercle  bacillus  itself.  The  diseased  animal  is  the  only 
manufacturer  of  tubercle  bacilli,  as  well  as  the  chief  disseminator. 
Tubercle  bacilli,  after  having  left  the  body  of  the  cow  (and  usi^ally 
in  small  numbers),  do  not  increase  in  nature,  but  suffer  a  steady 
decrease  and  final  extermination  in  four  to  six  months  at  the  long- 
est. Only  after  they  have  entered  the  bodies  of  susceptible  ani- 
mals, do  they  again,  begin  to  multiply.  Hence,  with  this  disease, 
the  only  danger  to  other  herds  lies  in  direct  association,  or  in  the 
transfer  of  a  diseased  animal  or  of  mük  from  such  an  animal. 
The  great  danger  exists  in  the  immediate  surroundings  of  the  in- 
fected, and  loses  itself  as  the  distance  increases. 

"Peeventive  Measures. 

"The  suggestions  to  be  recommended  are  not  to  be  considered 
as  taking  the  place  of  any  more  sweeping  and  radical  measures 
which  have  been  contemplated  by  some  States,  and  are  actually 
being  tried  in  others.  We  wish  them  to  be  considered  simply  as 
of  educational  value  to  the  owners  of  cattle  ia  their  efforts  to  re- 
press and  stamp  out  the  disease.  The  aid  of  the  Government  ia 
this  matter  is  a  question  to  be  discussed  by  itself.  Without  in- 
dividual co-operation  and  sacrifice,  directed  by  an  intelligent  under- 
standing of  the  disease  in  its  various  aspects,  any  efforts  on  the  part 
of  the  Government  are  likely  to  prove  abortive,  owing  to  the  enor- 
mous interests  involved. 

"Removal  of  Diseased  Animals. — This  is  the  essential  require- 
ment in  the  suppression  of  tuberculosis.  We  have  already  stated 
that  only  in  the  diseased  animals  the  tubercle  bacilli  multiply. 
Hence,  if  these  are  removed  and  the  stables  thoroughly  disinfected, 
so  that  any  germs  shed  by  them  are  destroyed,  we  are  safe  in  con- 
cluding that  the  disease  has  been  suppressed. 


48  TUBERCULOSIS  AS  A  DISEASE   OF  THE   MASSES 

"The  disease  in  tlie  early  stages  can  be  detected  only  with  the 
aid  of  tuberculin.  In  the  advanced  stages  most  careful  observers 
will  probably  recognize  it,  or  at  least  suspect  it,  without  the  use 
of  tuberculin.  Tuberculin,  therefore,  has  become  indispensible  in 
giving  the  owner  an  idea  of  the  inroads  the  disease  is  making  in 
his  herd,  and  in  distinguishing  the  infected  from  the  non-infected. 
Tuberculin  reveals  to  us  all  stages,  from  the  earliest,  most  insig- 
nificant changes,  when  the  animal  is  outwardly  entirely  well,  to 
the  gravest  and  most  dangerous  types  of  the  disease.  Tuberculin 
does  not,  as  a  rule,  discriminate  between  these  cases.  Hence,  those 
who  use  it  as  a  guide  must  not  be  disappointed  when,  after  having 
killed  the  suspected  ones,  they  find  that  many  are  in  the  earlier 
stages  of  the  malady.  Tuberculin,  moreover,  is  not  infallible.  A 
small  percentage  of  cases  of  disease  are  not  revealed  by  it.  On 
the  other  hand,  a  sound  animal  now  and  then  gives  the  reaction 
of  tuberculosis.  These  lapses  must  be  borne  in  mind  in  using 
tuberculin.  In  spite  of  them,  however,  tuberculin  must  be  con- 
sidered as  of  great  value  in  revealing  tuberculosis  not  recognizable 
by  any  other  means  during  life. 

"  The  question  next  arises,  What  shall  be  done  with  the  infected 
animals  ?  This  question  is  really  composed  of  two  distinct  ques- 
tions whose  combination  is  mainly  the  cause  of  the  present  per- 
plexity. From  the  standpoint  of  the  agricultmist  alone  the  matter 
is  simple  enough.  The  infected  animals  might  be  separated  at  once 
from  the  non-infected.  The  worst  cases  should  be  killed  and  buried 
deeply  or  bm-ned.  Those  without  outward  signs  of  disease  might 
be  fattened  for  the  butcher  and  inspected  at  the  abattoir.  This  is 
the  recommendation  given  by  Nocard,  a  prominent  French  author- 
ity, and  generally  followed  in  European  countries.  But  at  this 
point  public  health  appears  and  demands  the  prompt  and  complete 
destruction  of  all  infected  animals,  however  mild  the  disease,  or,  if 
the  animal  be  not  destroyed,  the  rejection  of  the  milk  of  all  in- 
fected animals.  The  interests  of  the  stock  owner  and  of  public 
health  are  thus  diametrically  opposed.  If  the  demands  of  public 
health  were  in  every  sense  justifiable,  from  a  strictly  scientific 
standpoint,  there  could  be  no  question  as  to  an  entire  submission 
to  its  demands.     But  the  case  is  not  so  simple,  and  gives  room  for 


AND  HOW  TO   COMBAT  IT.  49 

diversity  of  opinion.  Leaving  the  public-health  aspect  of  the 
question  aside  for  the  moment,  let  us  return  to  the  farmer's  side  of 
it.  After  all  infected  animals  have  been  segregated  or  killed,  as 
-the  case  may  be,  and  the  stables  disinfected,  the  remaining  healthy 
animals  should  be  retested  with  tuberclin  within  a  certain  period  of 
time,  fi'om  three  to  six  months  after  the  first  test,  to  make  sure 
that  no  disease  has  been  overlooked.  Future  repetitions  must  be 
recommended,  according  to  our  present  knowledge,  for  some  cases 
may  have  been  missed  by  the  tuberculin,  or  the  disease  germs  may 
possibly  be  reintroduced  by  tuberculous  human  beings,  or  by  tuber- 
culous cats,  dogs   or  other  domesticated  animals. 

"All  animals  introduced  into  a  herd  must  have  been  tested  and 
found  to  be  sound  beforehand.  This  is  such  a  self-evident  prop- 
osition that  it  needs  no  comment. 

"  In  the  absence  of  the  tuberculin  test,  or  of  organized  ofl&cial 
inspection,  the  stock  owner  should  carefuUy  and  promptly  remove 
from  his  herd  and  have  destroyed : 

"  (1)  All  animals  which  show  emaciation,  with  coughing,  and 
any  suspicious  discharges  from  the  nose. 

"  (2)  Those  animals  with  enlarged,  prominent  glands  about  the 
head  (in  front  of  the  ears,  under  or  behind  the  lower  jaw),  or  en- 
larged glands  in  front  of  the  shoulder,  in  the  flank,  and  behind  the 
udder,  and  all  animals  having  swellings  on  any  part  of  the  body 
which  discharge  a  yellowish  matter  and  refuse  to  heal. 

"  (3)  Animals  with  suspected  tuberculosis  of  uterus  and  udder. 

"Disinfection  and  other  Preventive  Measures. — It  will  probably 
require  more  or  less  time  before  the  use  of  tuberculin  will  have 
become  generally  established.  Hence,  preventive  measures  of  a 
general  character  must  still  be  kept  in  view  for  some  time  to  come. 
These  measures  partly  suffer  shipwreck  from  the  fact  that  it  is 
difficult  without  tuberculin  to  recognize  even  advanced  disease 
during  life.  Still,  much  can  be  done  to  reduce  the  amount  of  in- 
fection by  following  out  certain  general  and  specific  suggestions 
which  the  renewed  study  of  the  disease  has  either  originated  or 
else  placed  on  a  more  substantial  basis. 

"  Perhaps  the  most  important  preliminary  suggestion  to  be  made 
is,  that  the  owner  of  cattle  should  endeavor  to  familiarize  himself 
4 


50  TUBERCULOSIS  AS  A  DISEASE   OF  THE  MASSES 

as  much  as  possible  witli  the  general  nature  of  tuberculosis,  its 
cause,  the  ways  in  which  the  vhus  may  leave  the  body  of  the  sick 
and  enter  that  of  the  well,  and,  lastly,  the  ways  in  which  it 
spreads  within  the  body.  He  will,  by  the  acquisition  of  such  fun- 
damental knowledge,  lift  himself  above  the  plane  where  quackery 
and  specifics  abound,  and  understand  precisely  what  to  expect  after 
the  disease  has  entered  his  herd,  and  how  to  meet  the  demands 
of  public  health.  He  should,  however,  make  himself  acquainted 
with  the  peculiar  appearance  of  tuberculous  growths  in  the  body, 
and  open  every  animal  that  dies,  so  that  he  may  know  to  what  ex- 
tent his  animals  are  dying  of  this  malady.  Wlierever  possible  the 
services  of  the  skilled  veterinarian  should  be  made  use  of.  Sani- 
tary precautions  should  begin  with  the  removal  of  diseased  and 
suspected  animals,  as  stated  above.  This  is  the  most  essential 
requirement,  for  diseased  animals  are  the  only  breeding  places  of 
the  specific  virus. 

"  After  the  removal  of  these,  attention  should  be  paid  first  of  all 
to  the  stables.  Here,  during  the  long  confinement  of  the  winter 
months,  when  ventilation  is  all  but  suppressed,  we  may  look  for 
the  source  of  most  of  the  inhalation  diseases  so  common  in  tuber- 
culous cattle.  Even  when  only  a  few  cases  of  tuberculosis  have 
been  found,  the  stables  should  be  disinfected  by  removal  of  aR  dirt 
and  the  subsequent  application  of  disiufectants.  Since  tubercle 
bacilli  are  more  resistant  than  most  other  disease  germs,  the 
strength  of  the  disiafectiug  solution  must  not  be  less  than  as 
given.     The  following  substances  may  be  used : 

"(a)  Corrosive  sublimate  (mercuric  chloride),  one  ounce  in  about 
nght  gallons  of  water)  one-tenth  of  one  per  cent.).  The  water 
should  be  kept  in  wooden  tubs  or  barrels  and  the  sublimate  added 
to  it.  The  whole  must  be  allowed  to  stand  twenty-four  hours,  so 
as  to  give  the  sublimate  an  opportunity  to  become  enthely  dis- 
solved. Since  this  solution  is  poisonous,  it  should  be  kept  weU 
covered  and  guarded.  It  may  be  applied  with  a  broom  or  mop 
and  used  freely  in  aU  parts  of  the  stable.  Since  it  loses  its  virtue 
in  proportion  to  the  amount  of  dht  present,  all  manure  and  other 
dirt  should  Ije  first  removed,  and  the  stables  well  cleaned  before 
applying  the  disinfectant.     After  it  has  been  applied,  the  stable 


AND  HOW  TO  COMBAT  IT.  61 

should  be  kept  vacant  as  long  as  possible.  Before  animals  are 
allowed  to  return,  it  is  best  to  flush  those  parts  which  the  animals 
may  reach  with  their  tongues,  to  remove  any  remaining  poison. 

"  (b)  Chloride  of  lime,  five  ounces  to  a  gallon  of  water  (four  per 
cent.).     This  should  be  applied  in  the  same  way. 

"(c)  The  following  disinfectant  is  very  serviceable.     It  is  not 

so  dangerous  as  mercuric  chloride,  but  is  quite  corrosive,  and  care 

should  be  taken  to  protect  the  eyes  and  hands  from  accidental 

splashing. 

Gallon 

Crude  carbolic  acid -J 

Crude  sulphuric  acid -J- 

"  These  two  substances  should  be  mixed  in  tubs  or  glass  vessels. 
The  sulphuric  acid  is  very  slowly  added  to  the  carbolic  acid.  Dur- 
ing the  mixing  a  large  amount  of  heat  is  developed.  The  disin- 
fecting power  of  the  mixture  is  heightened,  if  the  amount  of  heat  is 
kept  down  by  placing  the  tub  or  glass  demijohn  containing  the 
carbolic  acid  in  cold  water  whue  the  sulphuric  acid  is  being  added. 
The  resulting  mixture  is  added  to  water  in  the  ratio  of  one  to 
twenty.  One  gallon  of  mixed  acids  wül  furnish  twenty  gallons  of 
a  strongly  disinfectant  solution  having  a  slightly  milky  appearance. 

"  (d)  Whitewash  is  not  in  itself  of  sufficient  strength  to  destroy 
tubercle  bacilli,  but  by  imprisoning  and  incrusting  them  on  the 
walls  of  stables  they  are  made  harmless  by  prolonged  drying. 
Whitewashing  should  be  preceded  by  thorough  cleaning. 

"Particular  attention  should  be  paid  to  the  sides  and  ceuings  of 

stables.     All  dust  and  cobwebs  should  be  periodically  washed  „     . 

^  "^  Hygiene  oi 

down.     Those  parts  coming  in  contact  with  the  heads  of  cattle.      Stables. 

stanchions,  halters,  troughs,  etc.,  should  be  frequently  cleansed  and 
disinfected,  even  when  they  have  not  been  used  by  diseased  cattle. 
"  The  removal  of  vnus  from  the  stables  should,  furthermore,  be 
promoted  by  the  regular  removal  of  manure  and  by  abundant  ven- 
tilation. Good  air  has  the  effect  of  diluting  infected  air,  and 
thereby  reducing  the  chance  of  inhaling  dried,  floating  tubercle 
baculi,  or  at  least  of  reducing  the  number  inhaled.  It  likewise 
improves  the  vigor  of  the  confined  animals,  and  hence  increases 
the  resistance  to  infection. 


5Ö  TTTßERCULOStS  AS  A  DISEASE  OB'  THE  MASSES 

"Cattle  should  not  be  placed  so  that  their  heads  are  close  to- 
gether; each  animal  should  have  plenty  of  room  (each  cow  should 
have  at  last  six  hundred  cubic  feet  of  air  space)  and  occupy  tha 
same  place  in  the  stable  at  all  times.  These  precautions  will  pre- 
vent the  nasal,  lung,  or  vaginal  discharges  from  one  animal  strik- 
ing the  head  or  soiling  the  feed  of  another.  It  is  true  that  it  is 
impossible  to  prevent  animals  licking  each  other  outside  of  the 
stable,  but  it  should  be  remembered  that  prevention  must  begui 
with  the  removal  of  all  cases  which  are  suspected  of  discharging 
tubercle  bacilli.  Stables  should,  fm*thermore,  be  carefully  pro- 
tected from  the  expectorations  of  human  beings  affected  with  tu- 
berculosis of  the  limgs. 

"  Cattle  should  be  housed  as  little  as  possible.  The  pasture  has 
the  effect  of  gi-eatly  reducing  the  chances  of  infection  by  a  more  or 
less  rapid  destruction  of  the  virus,  as  wellas  by  increasing  the  vigor 
of  the  animals  through  muscular  exertion  in  fresh  air.  To  what 
extent  animals  may  pick  up  the  virus  on  fields,  it  would  be  difficult 
to  estimate.  That  it  is  perfectly  possible  cannot  be  gainsaid.  A 
tuberculous  animal  may  soil  the  gi'ound  over  which  it  passes,  and 
other  animals  may  take  up  the  vii-us  with  the  food  soon  after. 

"  It  is  not  likely  that  the  virus  remains  alive  long  enough  on  the 
ground  to  become  dried  and  ready  for  inhalation.  The  action  of 
sunlight,  the  alternate  wetting  and  drying  which  goes  on  in  nature, 
may  be  looked  upon  as  destructive  agents.  Even  if  the  tubercle 
bacilli  became  speedily  dried,  the  great  diluting  effect  of  the  open 
air  would  reduce  to  a  minimum  the  chances  of  inhaling  the  virus. 

"  Among  the  other  dangers  deserving  attention  is  the  infection 
of  food  and  water.  Drinking  troughs  should  be  so  arranged  that 
the  surface  water  is  constantly  flowing  away.  Discharges  firom 
the  nose  or  mouth  left  floating  on  the  surface  may  be  drawn  in  by 
healthy  cattle  while  drinking.  Each  person  must  in  such  cases 
use  his  own  judgment  and  ingenuity  to  prevent  infection,  in  ac- 
cordance with  the  quantity  of  water  at  his  disposal. 

"  To  restrict  the  dissemination  of  the  disease  among  young  stock, 
the  safest  plan  is  to  brmg  skimmed  milk  and  other  dairy  products 
to  the  boiling  point  before  feeding  them.  If  the  cows  are  posi- 
tively known  to  be  healthy,  this  may  be  unnecessary,  but  where 


AND  HOW  TO   COMBAT  IT.  53 

any  doubt  exists  the  heating  should  be  resorted  to.  Such  a  pre- 
caution will,  fui-thermore,  reduce  scouring  among  calves,  which  is 
probably  due  in  a  great  measure  to  bacteria  in  the  food. 

"  In  presenting  the  foregoing  suggestions  the  writer  has  endeav- 
ored to  keep  in  view  two  conditions :  (1)  That  in  which  tuberculin 
is  not  withm  reach  and  only  unusual  watchfulness  can  be  exer- 
cised in  separating  suspected  animals  from  the  healthy,  and  (2) 
that  in  which  tuberculin  is  tried,  but  with  a  view  that  it  is  not 
wholly  infallible  and  requhes  to  be  seconded  with  other  precau- 
tionary measures.  If  tuberculin  is  infallible,  most  of  the  sugges- 
tions made  faR  to  the  ground  as  uimecessary,  unless  the  disease 
can  be  readuy  introduced  by  man  or  diseased  animals  of  other 
species,  a  possibility  of  wholly  unknown  dimensions  at  present." 

We  wül  only  add  to  these  valuable  instructions  that  tuberculin 
is  a  substance  invented  by  Prof.  Eobert  Koch  for  the  purpose  of 
diagnosing  tuberculous  diseases.  It  is  a  fluid  made  from  cultures 
of  the  germs  of  tuberculosis,  but  it  does  not  contain  either  dead  or 
living  germs  of  tuberculosis,  because  it  has  been  sterilized  by  heat- 
ing, thus  killing  the  germs ;  and  filtered  through  porcelain,  so  that 
after  they  are  destroyed  they  are  completely  removed  fi'om  the  fluid. 

By  tuberculin  test  is  imderstood  the  process  by  which  tuberculin 
is  applied  to  an  animal  for  the  purpose  of  determining  whether  it  TubercTilin 
is  free  from,  or  afflicted  with,  tuberculosis.  In  making  the  test  it  Test. 
is  necessary  to  determine  the  normal  temperature  of  the  animal, 
and  then  inject  a  small  quantity  of  the  tuberculin.  If  the  animal 
has  tuberculosis,  its  temperature  will  rise  within  from  eight  to  six- 
teen hours  after  the  injection,  but  if  it  does  not  suffer  from  tuber- 
culosis, the  temperature  is  not  influenced. 

The  tuberculin  test  should  always  be  applied  by  a  competent 
veterinarian,  and  no  danger  wül  arise  to  the  animals,  for,  when 
properly  applied,  the  healthy  animal  is  never  aöected  thereby. 

Of  course,  there  are  conditions  in  animals,  as  there  are  in  man, 
which  predispose  to  the  disease.  The  breed  as  well  as  the  condi- 
tions under  which  an  animal  is  compelled  to  live  determine  its 
susceptibility.  We  believe  it  to  be  perfectly  safe  to  say  that  the 
suggestions  made  regarding  the  prevention  of  tuberculosis  in  man 
are  also  applicable  to  animals.     Light,  air,  cleanliness,  proper  food. 


64 


TUBERCULOSIS  AS  A  DISEASE   OF  THE  MASSES 


and  sufficient  exercise  are  essential  in  combating  tuberculosis  in 
the  bovine  race.  After  a  herd  has  been  freed  from  its  tuberculous 
members  and  a  strict  hygiene  has  been  instituted,  with  plenty  of 
room  for  every  animal,  there  will  be  little  danger  of  a  new  out- 
break of  the  disease. 

Of  course,  as  abeady  mentioned  in  Dr.  Smith's  instructions,  it  is 
essential  that  no  consumptive,  no  matter  in  what  stage  of  the  dis- 
ease, should  be  permitted  to  enter  these  stables.  To  have  cows 
attended  to  by  tuberculous  help  is  absolutely  dangerous.  Ex- 
pectorating en  the  floor  of  a  stable  should  be  as  strictly  prohibited 
as  in  the  dwelling  of  man.  If  there  is  any  disease  such  as  diar- 
rhoea, fever,  etc.,  about  the  dairy  or  farm  the  physician  should  be 
called  in.  Medical  advice  should  also  be  sought  in  cases  of  slowly 
healing  ulcers  and  sores.  Scrupulous  cleanliness  in  the  handling 
of  milk  and  butter  in  dairies  is,  of  course,  essential  and  aU  the 
vessels  used  should  be  thoroughly  cleaned  with  hot  water  before 
being  used  again. 

Tuberculosis  among  swine  is  not  so  rare  as  is  usually  assumed. 
Whue  the  disease  among  cows  may  not  always  be  recognized  by 
the  loss  of  fat  and  general  bad  appearance  (for  even  tuberculous 
cattle  can  be  fatted),  in  swine  tuberculosis  manifests  itself  at  a 
very  early  date  by  a  marked  emaciation.  Very  often  these  swine 
are  then  quickly  slaughtered  and  the  meat  made  into  sausages. 
That  through  such  procedures  the  health  of  the  consumers  is  en- 
dangered is  evident,  especially  when  one  considers  that  many 
kinds  of  sausages  are  eaten  without  being  cooked.  Tuberculosis 
among  young  swine  manifests  itself  most  frequently  in  the  form 
of  intestinal  troubles.  The  main  symptoms  of  the  disease  are  the 
loss  of  flesh  and  bad  appearance  already  mentioned,  a  pale  mucous 
membrane — that  is  to  say,  the  inner  lining  of  the  mouth  loses  its 
reddish  color — a  marked  diarrhoea,  flatulency  and  discharge  of 
gases.  If  there  is  tuberculosis  of  the  lungs,  cough  and  vomit- 
ing are  additional  symptoms.  In  both  forms  of  tuberculosis  a 
swelling  of  the  glands  around  the  neck  is  often  observed.  Wlien 
these  animals  are  slaughtered,  one  can  see  little  tubercles  or  ele- 
vations and  ulcerations  along  the  inner  walls  of  the  guts,  and  on 
the  surface  of  the  lungs.     As  soon  as  the  disease  is  discovered 


AND  HOW  TO   COMBAT  IT.  55 

among  the  animals,  the  sick  swine  should  be  separated  from  the 
healthy  ones.  A  veterinarian  should  then  be  consulted,  who  wül 
give  directions  for  the  destruction  of  the  tuberculous  meat  and  the 
disinfection  of  the  sties. 

The  prevention  of  tuberculosis  among  swine  is  not  so  difficult 
when  one  thinks  of  the  causes  of  the  disease.  A  sucking  pig  can 
be  infected  by  a  tuberculous  sow.  The  most  frequent  source  of 
tuberculosis  among  hogs,  however,  comes  from  feeding  them  on 
skimmed  mük  and  other  dairy  products  from  tuberculous  cows. 
A  few  cases  are  also  known  where  hogs  became  tuberculous  from 
eating  the  expectoration  of  consumptives. 

Tuberculosis  of  horses  is  rare  and  difficult  for  a  layman  to  recog- 
nize.    When  a  horse  with  a  seemingly  good  appetite  has  a  bad    TubercTilo- 
appearance  and  loses  flesh,  tires  easily,  and  is  short  of  breath,  one        sis  in 
should  think  of  tuberculosis.     Much  urinating  ana  a  high  tem-  Horses  and 
perature  (fever)  are  additional  symptoms  of  tuberculosis  in  horses.      .    .    ^^, 
When  such  conditions  are  discovered,  it  is,  of  course,  self-evident 
that  the  animal  should  be  isolated  imtil  the  veterinarian  arrives. 

Tuberculosis  among  goats  is  extremely  rare.  In  the  few  cases 
which  have  been  recorded  the  origin  of  the  disease  could  be  traced 
to  the  ingestion  of  mük  from  tuberculous  cows.  Dogs  take  the 
disease  when  living  with  consumptive  people,  and  the  infection 
probably  takes  place  through  ingesting  and  inhaling  infectious 
substances. 

CHAPTEE   XYII. 

What  ake  the  Occupations  in  Which  Tuberculous  Inva- 
lids, Even  in  the  First  Stages  of  the  Disease,  Should 
Not  be  Employed? 

There  are  certain  occupations,  especially  those  that  requii-e  a  long 
sojourn  in  the  open  air  every  day  without  too  much  bodily  exertion, 
which  tuberculous  invalids  in  the  first  stages  of  the  disease  may 
be  permitted  to  follow  in  their  own  interest  as  well  as  in  that  of 
their  fellow-men.  There  are,  on  the  other  hand,  certain  occupa- 
tions which  should  never  be  permitted  to  consumptives.  What 
we  have  said  in  the  preceding  chapter  concerniag  tuberculous 
help  about  cow  stables  and  the  possibility  of  their  propagating  the 


56 


TUBERCULOSIS  AS  A  DISEASE  OP  THE  MASSES 


Handling 

of 

Food 

Substances, 

Bread,  etc. 


Tuberculo- 
sis among 

Caged 
Animals. 


disease,  is,  of  course,  also  applicable  to  milk  dealers,  butchers, 
cooks,  bakers,  confectioners,  and  all  who  have  to  do  with  the 
preparation  or  sale  of  food  substances.  For  bread  to  be  handled 
b}^  tuberculous  bakers  or  bread  dealers  is  dangerous.  The  possi- 
bility of  infection  is  evident  when  one  considers  through  how 
many  hands  the  bread  passes  before  it  enters  the  mouths  of  the 
consumers,  and  that,  probably,  nobody  ever  thinks  of  cleaning  the 
bread  before  eating  it.  A  very  recommendable  practice  is  now  in 
vogue  in  some  of  the  large  bakeries  in  connection  with  the  hand- 
ling and  transporting  of  bread.  The  moment  the  bread  comes  out 
of  the  oven,  while  it  is  still  too  hot  to  be  handled,  it  is  placed,  by 
the  aid  of  a  shovel,  upon  a  piece  of  wrapping-paper  large  enough 
to  envelop  the  whole  loaf.  By  twisting  the  two  ends  of  the 
wrapper  the  bread  is  completely  enclosed. 

The  most  scrupulous  cleanliness  should  be  practised  wherever 
articles  of  food  are  handled  or  exposed  for  sale.  "We  have  aheady 
mentioned  in  Chapters  XIII.  and  XIV.  that  certain  occupations, 
such  as  those  of  stone-cutters,  printers,  and  cigar-makers,  render 
weak  individuals  particularly  prone  to  consumption ;  therefore,  any 
one  inclined  to  this  disease  should,  in  his  own  interest,  never 
pursue  such  an  occupation. 

Lastly,  we  must  mention  one  more  occupation  in  which  tuber- 
culous individuals  should  never  engage,  namely,  that  of  keepers  of 
animals  in  menageries.  Large  animals,  such  as  lions  and  tigers, 
also  the  larger  and  smaller  classes  of  apes,  are  subject  to  tubercu- 
losis when  in  captivity.  There  is  no  doubt  that  an  ape-house, 
visited  by  thousands  of  people,  old  and  young,  every  day,  must  be 
considered  dangerous  and  capable  of  propagating  the  germs  of  tu- 
berculosis among  the  visitors  if  some  of  the  animals  should  be 
tuberculous. 

CHAPTER   XVIII. 

What  are  the  Main  Signs  and  Symptoms  of  the  Beginning 
OF  Tuberculosis  of  the  Lungs  or  Consumption? 

These  symptoms  are  often  so  obscure  and  show  themselves  so 
gi-adually  that  they  are  frequently  overlooked  by  the  patient  as 
well  as  by  his  friends.     Since,  however,  the  cure  of  the  patient 


AND   HOW   TO   COMBAT  IT.  S7 

depends  upon  the  early  discovery  of  the  disease  and  a  timely  treat- 
ment, we  will  here  describe  such  symptoms  as  may  be  recognized 
by  the  layman. 

The  man,  woman,  or  child  with  a  hereditary  predisposition  to 
consumption  often  has  a  narrow  chest  and  stooping  shoulders. 
While  a  slow,  gradual  emaciation  and  loss  of  weight  may  at  times 
be  observed,  this  is  by  no  means  a  rule.  One  occasionally  sees 
tuberculous  patients  who  present  a  relatively  good  appearance  dur- 
ing the  first  stage  of  the  disease.  Paleness  of  the  skin,  at  times 
with  bright  red  cheeks,  is,  however,  a  rather  common  early  sign. 
A  marked  inclination  to  frequent  catarrh  is  often  present,  and  the 
character  and  disposition  of  the  individual  may  change  when  the  Importance 
disease  comes  to  an  outbreak.  There  is  a  dislike  to  work,  also  to  ^^  Early 
the  pleasures  and  occupations  which  the  invalid  formerly  loved  to  Consumn- 
jursue.  He  will  probably  also  complain  of  getting  tired  easily.  tion. 
In  the  afternoon  hours  he  will  have  a  light  fever,  and  a  hacking 
cough  in  the  morning  or  evening.  Dyspepsia  and  loss  of  appetite, 
palpitation  of  the  heart  and  pains  in  the  chest,  are  also  symptoms 
of  importance.  Of  course,  some  or  several  of  these  signs  and 
symptoms  may  also  be  the  indication  of  the  approach,  of  other  dis- 
eases than  tuberculosis  of  the  lungs.  The  presence  of  such  symp- 
toms should,  however,  serve  to  all,  whether  predisposed  to  tuber- 
culosis or  not,  as  a  warning  to  seek  medical  advice.  Especially 
persons  who  cough  more  or  less  continually  should* submit  them- 
selves to  a  thorough  examination.  The  science  of  medicine  has 
made  such  progress  that  the  recognition  of  a  beginning  tuberculo- 
sis of  the  lungs  no  longer  presents  any  difficulty ;  therefore,  when- 
ever there  is  a  suspicion  of  the  begianing  of  consumption,  the  call- 
ing in  of  a  physician  may  assure  cure  and  restoration  to  health, 
and  if  no  tuberculosis  is  present  the  medical  examination  will  quiet 
imnecessary  fears. 

CHAPTEE   XIX. 

What  are  the  Early  Symptoms  of  Other  Forms  of  Tu- 
berculosis ? 

In  case  of  tuberculosis  of  the  throat,  the  general  symptoms  are 
about  the  same  as  those  just  described  for  the  begianing  of  con- 


68  TUBERCULOSIS   AS   A  DISEASE   OF   THE   MASSES 

sumption  of  the  lungs;  but  in  addition  there  will  be  a  certain 
Earlv        hoarseness  and  roughness  of  the  voice.     Pain  in  swallowing  very 
Symptoms    hot  and  -cold  liquids  or  hard  food  may  also  sometimes  be  observed 
of  Throat     jn  the  early  stage  of  this  disease. 

u  ere  -  rj,-^^  early  symptoms  of  tuberciilosis  of  the  bones  and  joints 
manifest  themselves  in  lameness  and  easy  tiring  of  the  arm  or  leg 
affected.  A  light  pressure  in  ths  region  of  the  joints  causes  a 
sudden  severe  pain.  If  the  spinal  column  is  affected,  the  symp- 
toms will  depend  upon  the  location  of  the  vertebra  which  is 
attacked  by  the  disease.  For  example,  if  this  should  be  in  the  re- 
gion of  the  neck,  there  will  be  difficulty  in  swallowing,  in  breath- 
ing, or  a  frequent  dry  cough.  If  any  one  of  the  vertebrae  in  the 
region  of  the  chest  is  affected,  a  feeling  of  constriction  like  a 
tight  band  around  the  chest  will  be  observed,  accompanied  often 
by  digestive  troubles.  If  the  seat  of  the  disease  is  the  lower  por- 
tion of  the  spinal  column,  there  will  be  irritation  of  the  bladder 
and  lower  bowels,  an  inclination  to  much  urinating,  and  radiating 
pains  toward  the  hips. 

It  is,  of  course,  self -understood  that  when  any  of  these  symp- 
toms are  discovered  the  physician  should  be  called  in,  for  only 
through  the  most  careful  treatment  can  a  patient  be  saved  from  a 
lasting  deformity. 

The  bone -and- joint  tuberculosis  is  most  frequent  duriag  child- 
hood.    The  same  may  be  said  of  that  form  of  tuberculosis  which 
Early  Signs  is  known  as  scrofula,  and  which  might  be  considered  almost  ex- 
^^  clusively  a  disease  of  children.     The  scrofulous  child  is  usually 

pale  with  flabby  skin  and  muscles.  The  glands  around  the  neck 
are  swollen,  and  skin  disease,  sore  eyes,  and  running  ears  are  fi'e- 
quent  symptoms.  The  little  patient  usually  manifests  a  phleg- 
matic condition,  but  we  may  also  find  some  that  are  nervous  and 
irritable.  The  latter  often  have  a  particularly  white,  delicate 
skin,  which  makes  the  vems  visible.  Fever  may  be  observed  in 
some  chüdreu.  In  view  of  the  happily  very  cm-able  nature  of 
scrofulous  affections,  the  importance  of  the  early  recognition  and 
of  the  timely  and  judicious  treatment  is,  of  com-se,  self-evident. 


AND   HOW   TO   COMBAT  IT. 


59 


CHAPTEE   XX. 

How  CAN  Childeen  be  Pkotected  fkom  Sckofula  and  Other 
Forms  of  Tuberculosis  ? 

Scrofula  may  be  either  hereditary  or  acquired.  The  hereditary 
type  comes  from  parents  who  are  scrofulous,  tuberculous,  or  syphi- 
litic. It  has  also  been  proved  that  when  one  or  both  of  the  par- 
ents were  alcoholics,  that  is  to  say,  addicted  to  the  chronic  use  of 
intoxicants,  their  offspring  has  become  scrofulous. 

All  this  shows  how  dangerous  it  is  for  weakly  and  sickly  per- 
sons, or  those  afflicted  with  any  of  the  above  enumerated  diseases, 
to  marry  and  have  children  before  being  completely  restored  to 
health.  We  wish  to  state  again  that  all  these  diseases  can  be 
cm-ed  by  timely  medical  treatment.  To  be  cured  from  alcoholism 
the  physician's  help  is  not  always  necessary;  inmost  cases  it 
requires  only  the  earnest  and  honest  endeavor  to  abstain. 

The  causes  of  acquired  scrofula  in  children  are  to  be  sought  in 
unhygienic  environments  and  conditions,  such  as  unhealthy  dwell- 
ings, damp,  crowded,  unclean,  and  badly  ventilated  rooms,  much 
indoor  life,  underfeeding,  exposiKC,  and  colds  brought  about  by 
insufficient  clothing  and  lack  of  care.  In  fact,  one  may  say  the 
same  conditions  which  produce  favorable  soil  for  the  invasion  of 
the  germs  of  consumption  in  the  adult  are  conducive  to  the  de- 
velopment of  scrofula  in  chudren.  How  these  conditions  are  to 
be  overcome  we  have  endeavored  to  explain  in  Chapters  XII.,  XIV., 
and  XV.,  and  we  will  speak  of  them  in  their  sociological  aspect  in 
Chapter  XXVIII. 

On  page  41  we  stated  that  it  is  extremely  rare  for  tuberculosis  to 
be  directly  transmitted,  and  that  in  chudren  the  contagion  nearly 
always  takes  place  while  they  are  very  young.  We  will  now  ex- 
plain the  various  ways  in  which  a  healthy  chüd  may  become 
tuberculous,  and  learn  therefrom  how  to  protect  it  from  the  dan- 
ger of  getting  the  disease,  either  by  inhalation,  ingestion,  or  inoc- 
ulation. 

The  most  common  modes  of  infection  during  early  chudhood 
are  perhaps  the  following:  The  consumptive  mother  cai^esses  the 


60 


TUBERCULOSIS   AS   A  DISEASE   OF  THE   MASSES 


child  and  kisses  it  on  the  mouth ;  she  prepares  the  food,  tasting  it 
to  judge  its  temperatui-e  and  flavor  through  the  same  rubber  nipple 
or  with  the  same  spoon  the  child  uses,  and  thus  unconsciously 
conveys  the  germs  of  her  disease  from  her  own  mouth  to  that  of 
the  child.  Later  on  the  child  will  play  on  the  floor  of  the  room, 
and  should  there  be  a  consumptive  in  the  family  who  from  care- 
lessness or  ignorance  is  not  prudent  in  the  disposal  of  his  expec- 
toration, the  child  is  indeed  likely  to  be  infected.  The  little  one, 
while  playing  on  the  floor,  may  with  gi-eat  facility  inhale  the 
bacilli  floating  with  the  dust  in  the  ah,  and  can  thus  acquire 
tuberculosis  by  inhalation,  the  full  development  of  which  may 
only  take  place  in  later  years,  when  the  origin  will  not  be  thought 
of.  Again,  the  little  chud  touches  everything  it  can  take  hold  of, 
infectiug  its  fingers  thoroughly,  and  by  putting  them  in  its  mouth 
tuberculosis  by  ingestion  may  result  and  gradually  develop  into 
consumption  of  the  bowels.  Lastly,  should  the  chud's  naüs  be 
neglected,  it  may  scratch  itself  with  the  infected  fingers,  and  thus 
inoculate  its  system  with  the  disease.  Tuberculosis  of  the  skin, 
or  lupus,  may  result  from  such  an  unfortunate  accident. 

To  prevent  these  infections  durmg  childhood  is  certainly  pos- 
sible by  taking  the  foUowing  precautions :  Not  only  should  con- 
sumptives be  religiously  careful  with  their  expectoration,  but  they 
should  associate  as  little  as  possible  with  young  children,  and  stay 
away  from  playrooms  and  playgrounds.  We  repeat  that  to  kiss 
children  on  the  mouth  should  never  be  allowed,  and  the  little 
ones  should  be  taught  never  to  kiss  nor  be  kissed  by  strangers, 
They  .should  be  kissed  by  theh  own  friends  and  relatives  as  little 
as  possible,  and  then  only  on  the  cheeks.  The  floor  on  which  the 
chud  X'lays  should  be  kept  scrupulously  clean.  Carpets  in  such  a 
place  are  an  abomination ;  they  only  serve  as  dust  and  dirt  collec- 
tors, and  not  mfrequently  harbor  the  germs  of  contagious  diseases. 
The  hands  and  nails  of  little  children  should  be  kept  as  clean  as 
possible. 

Expectorating  on  playgrounds  should  be  considered  a  grave 
offence  and  should  be  punished  accordingly.  These  playgrounds 
sliould  be  kept  clean,  as  free  from  dust  as  possible,  and  daily 
strewn  with  clean  sand  or  gi-avel. 


AND  HOW  TO  COMBAT  IT. 


61 


CHAPTER   XXI. 

Can  Tuberculosis,  Especially  in  Its  Pulmonary  Form,  or 
Consumption  of  the  Lungs,  be  Cured  ? 

This  question  can  be  answered  with  a  very  decided  Yes.  Of 
eminent  men  of  the  past  and  present,  who  in  their  youth  or  early 
manhood  were  declared  to  be  consumptive,  but  who  attained, 
nevertheless,  a  more  or  less  advanced  age,  may  be  mentioned  the 
German  poet  Goethe,  Napoleon  the  First,  and  our  own  Peter 
Cooper.  Dr.  Hermann  Brehmer,  one  of  the  foremost  German 
physicians,  was  a  consumptive  when  he  started  the  first  sanato- 
rium for  tuberculous  patients  in  1859,  over  which  he  presided  for 
more  than  thirty  years  with  great  success.  His  most  celebrated 
pupil,  Dr.  Dettweiler,  entered  his  sanatorium  as  a  consumptive, 
became  Brehmer' s  assistant,  and  has  since  been  for  twenty-five 
years  active  as  the  medical  director  of  the  Falkenstein  Sanatorium. 
The  late  Dr.  Pean,  of  Paris,  who  died  at  the  age  of  sixty-five,  was 
declared  phthisical  when  twenty.  Francis  Copp^e,  one  of  the 
greatest  poets  of  modern  France,  takes  delight  in  telling  that  more 
than  twenty  years  ago  a  life  insurance  company  refused  to  insure 
him,  because  he  was  declared  consumptive,  and  how  badly  the  com- 
pany ought  to  feel  now,  having  lost  his  premiums  for  over 
twenty  years !  There  are  thousands  of  such  cases  where  people, 
once  declared  consumptive  by  competent  physicians,  have  ulti- 
mately recovered,  and  pursued  their  vocations  in  life  with  imim- 
paired  vigor  for  many  years  afterward. 

The  statistics  from  sanatoria  for  consumptives,  where  patients 
in  all  stages  of  the  disease  are  received,  show  that  twenty -five 
per  cent,  leave  as  absolutely  cured,  and  forty  to  fifty  per  cent, 
leave  much  improved,  many  of  them  being  again  capable  of  earn- 
ing their  living.  In  institutions  where  only  patients  in  the 
early  stages  of  the  disease  are  received,  as  many  as  seventy  to 
seventy-five  per  cent,  have  been  cured. 


Celebrated 
Men  Who 
were  Cured 
of 
Consump- 
tion. 


Results 

Obtained  in 

Sanatoria. 


62 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Reports 

from 

Dettweiler, 

Wolff, 

Hauffe, 

Von  Ruck, 

and 
Baldwin. 


CHAPTEK   XXII. 

Have  the  Fokmek  Patients  Who  Left  Sanatoria  or  Special 
Institutions  for  the  Treatment  of  Consumption  as  Cured, 
Eemained  Lastingly  So? 

That  a  lasting  cure  of  consumption  is  possible  we  have  shown 
in  the  preceding  chapter  by  enumeratiag  the  names  of  some 
gi-eat  men  who  were  consumptive  in  their  youth,  but  were  cured 
and  lived  a  long  and  useful  life,  some  even  attaining  a  ripe  old  age. 

Concerning  the  duration  of  cures  accomplished  in  sanatoria  and 
special  hospitals  for  consumptives,  we  will  reproduce  some  of  the 
statistics  published  in  recent  years.  Among  99  patients  dis- 
charged from  the  Falkensteia  Sanatorium  as  cured,  72  were  well 
at  the  time  the  inquiry  was  made,  which  was  three  to  nine  years 
after  the  patients  had  Ißft  the  sanatorium.  In  15  cases  a  re- 
lapse had  occurred,  but  12  of  these  patients  had  improved  again; 
12  of  the  99  had  died.  Dr.  Wohf  s  inquiries  concerning  95  pa- 
tients discharged  as  cured  from  Brehmer's  institution  in  Goerbers- 
dorf ,  resulted  in  the  following :  5  were  alive  and  well  after  a  period 
of  from  21  to  29  years;  52  were  well  after  a  period  of  from  12  to 
21  years;  and  38  were  well  after  a  period  of  from  7  to  12  years. 
Dr.  Hauffe,  of  the  St.  Blasien  Sanatorium  in  Germany,  wrote  in 
1891  to  324  former  patients  who  had  left  the  institution  between 
1879  and  1889.  Forty-six  did  not  reply,  5  were  reported  dead, 
12  had  grown  worse,  201  thought  themselves  still  relatively  cured, 
and  72  were  absolutely  cured.  Dr.  von  Euck,  of  Asheville,  N. 
C,  reported  to  the  author  of  this  essay  that  he  had  written  to  650 
of  his  former  patients  who  had  left  the  sanatorium  from  one  to 
three  years  before;  457  responded,  directly  or  through  friends. 
Of  these,  67  felt  absolutely  cured;  70  felt  relatively  cured;  258 
felt  still  improved ;  62  got  worse  or  had  died.  Dr.  E.  Pt.  Baldwin, 
of  Saranac  Lake,  N.  Y.,  reported  recently  that  at  the  Adirondack 
Cottage  Sanatorium  they  were  in  constant  correspondence  with  115 
patients  wlio  had  been  discharged  within  the  last  ten  or  twelve  years, 
and  while  a  few  had  relapsed  slightly,  the  majority  were  well  at 


AND  HOW  TO   COMBAT  IT. 


63 


their  homes.  Of  course,  these  reports  do  not,  and  cannot,  corre- 
spond exactly.  With  the  exception  of  the  last-named  institution 
(Adhondack  Cottage  Sanatorium),  which  only  takes  patients  in  the 
earlier  stages,  those  sanatoria  receive  patients  for  treatment  in  all 
stages  of  the  disease.  But,  as  a  whole,  these  statistics  are  certainly 
encouraging,  and  the  question  "Can  consumption  be  lastingly 
cured  ? "  may  also  be.  answered  with  a  decided  Yes. 

Not  only  the  living  but  even  the  dead  give  us  absolute  proof  of 
the  curability  of  tuberculosis  of  the  lungs.  In  the  autopsies  (post- 
mortem examinations)  of  many  individuals  who  have  died  of  other 
diseases  than  consumption,  healed  scars  are  found  in  the  lungs, 
giving  the  visible  evidence  of  a  healed  tuberculosis.  Statistics 
concerning  this  occurrence  show  that  the  number  of  cases  of 
healed  tuberculosis  of  the  lungs,  discovered  at  autopsies,  is  nearly 
twenty-five  per  cent. 

Other  forms  of  tuberculosis  are  also  curable,  particularly  the 
forms  which  manifest  themselves  as  scrofula,  or  diseases  of  the 
bones  or  joints  in  children.  The  results  which  have  been  obtained 
in  sea-coast  sanatoria  and  special  hospitals,  of  which  a  number  exist 
in  France,  Germany,  Holland,  and  Italy,  are  well-nigh  surprising. 
According  to  a  recent  report  of  the  general  secretary  of  the  Society 
for  the  Creation  of  Sea-Coast  Sanatoria  for  Scrofulous  and  Tuber- 
culous Children  in  Germany,  no  less  than  fifty  per  cent,  of  these 
little  ones  leave  those  institutions  perfectly  cured. 

We  do  not  think  it  an  exaggeration  to  say  that  of  all  chronic 
diseases  tuberculosis  is  the  most  curable,  and  of  late  years  the 
most  frequently  cured.  After  these  glad  tidings  concerning  the 
curability  of  tuberculosis  in  general,  and  particularly  of  the  once 
so  very  much  feared  tuberculosis  of  the  limgs  or  consumption,  let 
us  ask  hoio  consumption  is  treated  and  cured. 


Pathologi- 
cal Proofs 

of  the 
Curability 

of 
Consump- 
tion. 


Other 
Forms  of 
Tuberculo- 
sis Also 
Curable. 


CHAPTEE  XXIII. 


What  are  the  Modeen  Methods  to  Treat  and  Cure   Con- 
sumption ? 

It  is  not  cured  by  quacks,  by  patent  medicines,  nostrums,  or 
other  secret  remedies,  but  solely  and  exclusively  by  scientific  and 


64  TUBERCULOSIS   AS  A  DISEASE   OF  THE  MASSES 

judicious  use  of  fresh  air,  sunshine,  water,  abundant  and  good  food 
(milk,  eggs,  meat,  vegetables,  fruit),  and  the  help  of  certain  medic- 
inal substances  when  the  just-mentioned  hygienic  and  dietetic 
means  do  not  suffice  in  themselves  to  combat  the  disease. 

The  thorough  and  constant  supervision  of  the  pulmonary  invalid , 
the  immediate  intervention  when  new  symptoms  manifest  them- 
selves or  old  ones  become  aggravated  or  do  not  disappear  rapidly 
enough,  the  prescribing  of  proper  food  and  drink,  can  only  be  done 
by  the  thoroughly  trained  physician.  Therefore,  right  here  let  us 
sound  a  note  of  warning ;  namely,  that  not  the  most  beautiful  cli- 
mate nor  the  most  delightful  resort  can  cure  the  consumptive 
patient  if  he  is  not  wisely  guided  in  his  treatment. 

Sometimes  this  class  of  patients  think  that  they  feel  well  enough 
to  no  longer  need  to  submit  themselves  to  the  control  of  their 
physician.  They  think  that  they  may  safely  piu-sue  pleasures, 
sometimes  even  excesses,  or  take  up  work  just  as  well  as  healthy 
people.  Such  carelessness  on  the  part  of  a  recovering  consumptive 
has  many  a  time  resulted  in  a  serious  relapse. 

The  thorough  belief  in  the  curability  of  pulmonary  tuberculosis, 

and  the  conviction  that  the  hygienic  and  dietetic  treatment  under 

constant  medical  supervision  could  be  most  successfully  carried  out 

„  y^^  ,      in  an  institution  exclusively  intended  for  that  purpose,  caused  Her- 

Supervision  mann  Brehmer,  the  German  physician  mentioned  above  among 

Essential  to  the  illustrious  men  cured  of  consumption,  to  establish  the  first  sana- 
^^^®'  torium  for  consumptives,  at  Goerbersdorf  in  Silesia  (1859);  al- 
though it  must  be  said,  in  justice  to  the  English  medical  world, 
that  special  hospitals  for  consumptives  were  erected  in  or  near 
large  cities  as  far  back  as  sixty  years  ago.  These  "special  hospi- 
tals "  for  consumptives  in  former  years  did  not  differ  much  from 
general  ones,  -while  a  sanatorium  for  consumptives  has  many  fea- 
tures by  which  it  differs  entirely  from  an  hospital.  Brehmer,  in 
his  day,  maintained  that  such  institutions  should  have  particular 
Special       climatic  conditions,  and  should  always  be  situated  at  a  consider- 

Advantaees  '^'^^®  elevation  above  the  sea  in  order  to  obtain  satisfactory  results. 
Not         Tlie  experience  of  more  recent  years,  however,  m  Europe  as  well 

Essential  to  as  in  the  United  States,  has  shown  that  properly  conducted  sana- 
toria or  modern  special  hospitals,  erected  in  regions  with  no  claims 


AND  HOW  TO   COMBAT  IT.  65 

for  special  climatic  advantages,  obtained  just  as  good  results  in  the 
end  as  institutions  situated  in  typical  climatic  resorts. 

To  give  the  layman  an  idea  of  what  is  understood  to-day  by  a^ 
closed  institution  or  sanatorium,  exclusively  intended  for  the  treat- 
ment of  consumptives,  we  will  answer  the  following  questions : 

CHAPTER   XXIV. 

What  is  a  Modeen  Sanatorium  for  Consumptives  ?  And  can 
Such  a  Sanatorium  Become  a  Danger  to  the  Neigh- 
borhood ? 

A  modern  sanatorium  *  for  the  treatment  of  consumptives  is  an 
institution  usually  situated  in  a  healthy  locality,  somewhat  elevated, 
relatively  free  from  dust  and  traffic.  Only  patients  suffering  from 
tuberculosis  are  received.  The  greatest  care  is  exercised  every- 
where, in  buildings  and  surroundings,  to  avoid  the  possible  trans- 
mission of  the  disease  to  employees,  visitors,  or  the  neighbors  of 
the  institution,  and  equally  great  care  is  exercised  to  prevent  a 
reinfection  of  the  patients  themselves.  All  the  precautions  enu- 
merated in  Chapters  IV.  and  V. ,  which  provide  for  the  destruction 
of  the  infectious  expectoration,  are  carried  out  with  the  utmost 
rigor  in  the  sanatorium.  A  voluntary  violation  of  rules,  relating 
to  the  disposal  of  the  expectoration,  is  followed  by  immediate  dis- 
missal of  the  offender. 

The  hygienic  and  preventive  measures  in  these  modern  sanatoria  Hygiene  in 
are  so  thorough  that  it  may  be  said  one  is  in  less  danger  of  becoming  the 

infected  with  the  germs  of  consumption  there  than  anywhere  else.  ^^^^^^O'^i'^^- 
It  is  of  the  rarest  occurrence  that  any  of  the  physicians,  nurses, 
or  employees  in  such  an    institution  contract  tuberculosis.     It 
seems  to  us  that  this  is  a  very  good  proof  of  how  easily  infection 

*Tlie  word  sanatorium  is  used  in  tliis  essay  in  preference  to  the  word 
"sanitarium"  for  the  following  reasons:  Brehmer,  the  founder  of  the  first 
institution  of  that  kind,  called  it  "  Heilanstalt,"  which  means  a  healing  insti- 
tution ;  and  the  word  "sanatorium,"  from  the  Latin  sanare,  to  heal,  gives  cer- 
tainly a  better  equivalent  to  the  German  word  than  the  word  "sanitarium." 
This  latter  word  is  derived  from  the  Latin  sanitas,  health,  and  is  usually  em- 
ployed in  this  country  to  designate  a  place  considered  as  especially  healthy,  a 
favorite  resort  for  convalescent  patients,  or  an  institution  for  the  treatment  of 
mental  or  nervous  diseases. 


ee 


TUBERCULOSIS   AS   A  DISEASE   OF   THE   MASSES 


Mortality 


can  be  avoided  when  physician  and  patient  work  together  to  com- 
bat the  tubercle  bacillus,  this  gi^eat  foe  of  mankind. 

Another  very  interestiug  observation  is  that  in  localities  where 
sanatoria  for  consumptives  are  situated,  the  mortality  from  con- 
sumption among  the  inhabitants  of  the  respective  villages  has 


Goerbers- 

dorf  and 

Falken- 

stein. 


Statistics  of  markedly  decreased  since  the  establishment  of  the  institution. 
The  splendid  hygienic  and  preventive  measures  instituted  in  the 
sanatoria  have  been  voluntarily  imitated  by  the  villagers,  and  as  a 
result  the  mortality  from  pulmonary  tuberculosis  among  the  in- 
habitants has  gradually  decreased.  Thus  we  are  glad  to  be  able 
to  answer  in  the  negative  the  question  so  important  in  the  combat 
of  tuberculosis  as  a  disease  of  the  masses,  "Are  sanatoria  for  con- 
sumptives a  danger  to  the  neighborhood  ? "  From  well-conducted 
sanatoria  for  consumptives  no  danger  can  arise  to  the  surroundings. 
To  confirm  this  statement  by  exact  statistics,  we  will  reproduce 
the  data  taken  from  the  official  documents  of  the  two  villages, 
Goerbersdorf  and  Falkenstein,  where  five  of  the  largest  German 
sanatoria  have  been  located  for  many  years. 

In  Goerbersdorf  the  deaths  from  consumption  were : 


1790-99 14 

1800-09 5 

1810-19 9 

1820-29 9 

1830-39 8 


1840-49 6 

1850-59 7 

1860-69 4 

1870-79 5 

1880-89 5 


The  sanatorium  in  Goerbersdorf  was  established  in  1859,  and 
since  then  the  population  of  the  village  of  Goerbersdorf  has 
doubled. 

In  the  village  of  Falkenstein  died  from  tuberculosis : 


Before  the  Establishment  of  the  Sanatorium. 

1856-58 17.2  per  100 

1859-61 7.7   " 

1862-64 22.6   " 

1865-67 14.0   " 

1808-70 16.7   " 

1871-73 21.0   " 

1874-76 33.3   " 


After  the  Establishment  of  the  Sanatorium.  _ 

1877-79 17.0  per  100 

1880-82 14.6 

1883-85 6.0 

1886-88 5.0 

1889-91 13.9 

1892-94 15.1 


The  patients  in  such  a  sanatorium  live,  so  to  speak,  day  and 

ro  onge      jjjgj^t;  in  tj^e  open  air.     During  the  day  they  lie  on  lounging  chairs 

in  the  Open  on  the  open  verandas  and  take  walking  and  breathing  exercises. 

Air.         and  at  night  they  sleep,  of  course,  with  the  windows  open.     It  is 


AND   novr   TO   COMBAT   IT. 


er 


surprising  how  easily  consumptives  get:  accustomed  to  the  pro- 
longed sojourn  in  the  open  air.  Neither  change  of  weather,  cold, 
rain,  snow,  nor  even  wind,  providing  it  is  not  too  strong,  hinders 


68 


TUBERCULOSIS   AS   A   DISEASE    OF   THE   MASSES 


the  patients  from  spending  most  of  tlieir  time  on  the  piazza,  porch, 
or  rest-cm-e  gallery.  Observations  made  by  the  house  physicians 
in  sanatoria  prove  that  the  change  of  weather  has  little  influence 
on  the  trained  consumptive  patient,  and  that  the  rest  cure  on  the 
galleries  of  the,  sanatorium  can  be  successfully  carried  out  in  win- 
ter or  summer,  rain  or  shine.  "Wlien  it  is  very  cold  patients  cover 
themselves  a  little  more  with  blankets  or  furs.  Dr.  Andvord,  of 
the  Tonsaasen  Sanatorium,  reported  that  his  patients  remained  in 
the  open  air  from  five  to  nine  hours  a  day  at  a  temperature  of 


Fig.  20.— a  German  Rest-Cure  Gallery. 

13°  F.  below  zero,  and  felt  very  well.  Similiar  reports  come  to  us 
from  that  excellent  American  institution,  the  Adirondack  Cottage 
Sanatorium,  imder  the  direction  of  Dr.  Edward  L.  Trudeau,  the 
pioneer  of  the  sanatorium  treatment  in  the  United  States.  We 
reproduce  a  photogra])]!  (Fig.  19)  taken  on  a  winter  day  at  that 
institution,  showing  how  well  and  comfortable  the  patients  are  in 
spite  of  the  cold.  We  also  give  a  typical  German  rest-cure  gal- 
lery or  "Liegehalle  "  (Fig.  20),  and  finally  a  picture  representing 
the  rest  cure  in  summer  in  the  woods  at  a  sanatorium  in  the  Black 
Forest  in  Germany  (Fig.  21).  The  latter  shows  how  the  patients 
in  a  sanatorium  know  how  to  have  a  good  time.     One  must  not 


AND   HOW  TO   COMBAT   IT, 


69 


think  these  institutions  dreary  and  cheerless  places.  The  major- 
ity of  the  patients  do  well,  as  a  rule,  and  progress  favorably  toward 
recovery.     As  a  consequence  they  feel  happy  and  impart  their  joy 


70 


TUBERCULOSIS   AS   A   DISEASE   OF   THE   MASSES 


and  good  humor  to  the  rest,  thus  helping  to  keep  all  the  patients 
in  good  cheer. 

The  discipline  in  these  institutions  deserves  by  no  means  to  be 
considered  an  objectionable  feature.  Discipline  in  a  sanatorium 
for  consumptives  is  as  essential  in  the  interest  of  the  patient  as 
for  everybody  else.  The  rules  and  regulations  of  the  institution 
are  for  the  common  good.  The  physicians  and  nurses  have, 
as  a  rule,  the  patience,  forbearance,  and  devotion  which  their 
calling  requhes;  but  when  it  is  necessary  in  the  interest  of  the 
patients  and  then  environments,  the  physician  must  have  the  right 
to  make  his  authority  felt.  A  sanatorium  shoidd  not  only  be  a  place 
where  a  patient  becomes  cured,  but  also  a  place  where  he  should 
learn  some  lessons  for  the  future.  All  that  he  will  have  learned 
from  the  rules  and  regulations,  and  the  advice  of  the  physician 
concerning  how  to  protect  himself  and  others  from  contracting  the 
disease,  how  not  to  take  cold,  and  how  not  to  lose  what  he  has 
gained,  are  precious  lessons  which  he  will  take  home  with  him. 

The  physician  of  the  consumptive,  whether  in  a  sanatorium  or 
at  home,  must  be  the  friend  of  the  patient,  and  have  his  unlimited 
confidence.  In  all  such  questions  as  marriage,  sexual  relations, 
and  childbhth,  the  physician's  advice  should  be  sought.  Much 
uuhappiness  and  family  misfortune  can  often  be  avoided  by  asking 
and  conscientiously  obeying  the  physician's  advice.  One  of  the 
main  features  of  sanatorium  treatment  is  ample  nutrition,  one 
might  even  say  overfeeding.  The  principal  meals  are  usually 
taken  in  well-ventilated  dining-rooms,  the  lunches  on  the  piazzas 
or  on  tlie  rest-cure  galleries.  Maay  patients,  in  order  that  they 
may  gain  more  rapidly  in  weight  and  strength,  receive  an  addi- 
tional quantum  of  fresh  millc  daily. 

On  arriving  at  the  mstitutiun  every  patient  is  carefully  examined 
and  weighed  by  the  physician,  and  this  process  is  repeated  at 
regular  intervals  during  the  entire  stay  of  the  patient  at  the  sana- 
torium. The  physician  in  charge  or  one  of  his  assistants  keeps 
regular  office  hours  for  the  convenience  of  the  patients.  Those 
who  are  unable  to  be  up  are  visited  twice  a  day  l)y  one  of  the  phy- 
sicians of  the  mstitution.  Specially  constructed  rooms  for  the  ap- 
plication of  cold  water,  one  of  the  means  of  treatment,  are  usually 


AND  HOW  TO   COMBAT  IT.  Yl 

located  in  the  basement,  or  the  apparatus  is  installed  in  a  neigh- 
boring building.  A  pharmacy,  a  laboratory,  and  a  room  for  the 
treatment  of  throat  diseases  usually  completes  the  equipment  of  a 
large  sanatorium. 

To  enable  the  poorer  classes  to  avail  themselves  of  the  advan- 
tages of  institution  treatment  for  consumptives,  noble-minded 
men  and  women,  philanthropists,  statesmen,  and  physicians  have 
in  recent  years  been  instrumental  in  creating  in  many  parts  of  Eu- 
rope and  in  some  parts  of  the  United  States  so-called  State  or  peo- 
ple's sanatoria  (Volksheilanstalten). 

CHAPTEE   XXV. 

What  Are  State  Sanatoria  ?    And  What  Are  "Volksheil- 
anstalten "  OR  People's  Sanatoria  ? 

A  State  sanatorium  in  the  United  States  means  an  institution 
for  the  exclusive  treatment  of  patients  suffering  from  pulmonary 
tuberculosis,  created  by  the  funds  of  the  State  and  supported  en- 
tii-ely  or  in  part  by  the  State.  The  first  State  sanatorium  in 
America  was  erected  a  few  years  ago  near  Eutland,  Mass.  In  this 
institution  patients  pay  fifty  cents  per  day.  Recently  other  States, 
New  York,  New  Jersey,  Iowa,  Illinois,  Maine,  etc.,  have  projected 
the  building  of  similar  institutions. 

People's  sanatoria  in  the  United  States  are  institutions  intended 
for  the  poor  and  people  in  moderate  circumstances,  erected  and 
maintained  by  private  philanthropy.  While  in  some  institutions 
patients  receive  medical  treatment  and  board  gratuitously,  in 
others  they  are  supposed  to  pay  part  of  the  expense. 

People's  sanatoria  in  Germany  have  a  somewhat  different  mean- 
ing. There,  the  moment  an  individual  enters  upon  the  career  of 
an  ordinary  laborer  or  servant,  he  is  obliged  to  be  insured  against 
sickness,  accidents,  and  old  age.  If  he  develops  tuberculosis,  he  is 
immediately  sent  to  one  of  the  many  sanatoria  of  that  country. 
The  government  authorities,  who  are  at  the  head  of  these  state  in- 
surance companies,  have  long  since  learned  that  by  timely  treat- 
ment in  a  sanatorium  the  tuberculous  individual  is  most  speedily 
and  lastingly  cured,  and  consequently  with  the  least  expense. 


Y2 


TUBERCULOSIS   AS   A   DISEASE   OF   THE   MASSES 


Thii'ty-seven  of  these  government  insurance  companies  have, 
according  to  their  published  figures  for  1897,  collectively  assisted 
4,480  consumptives,  of  whom  4,432  were  sent  to  subsidized  sana- 
toria. Nearly  all  these  state  insurance  companies  contribute  to 
the  funds  of  such  establishments ;  some  have  found  it  to  then  ad- 
vantage to  erect  special  sanatoria  of  then-  own.  For  the  year  1897 
these  state  insurance  societies  of  Germany  invested  altogether 
1,300,000  marks  in  sanatoria  for  consumptives,  and  in  1898  a  fund 
of  between  three  and  four  millions  was  destined  for  that  purpose. 

To  discuss  whether  such  state  invalidity  insurance  companies 
are  practicable  or  feasible  in  this  country  does  not  come  within  the 
scope  of  this  work.  Still  less  can  we  enter  into  a  discussion  of 
why  private  life  insurance  companies  will  not  insure  persons  among 
whose  near  relatives  consumption  has  occuiTed,  in  spite  of  the  evi- 
dent curability  of  the  disease.  While  it  is  most  gi-atifying  to  note 
that  some  States  have  undertaken  to  care  for  their  consumptive 
poor,  and  while  noble  men  and  women  have  privately  undertaken 
to  care  for  some  of  those  unfortunate  sufferers,  there  is  yet  a  gi-eat 
deal  to  be  done.  In  view  of  the  gi^eat  number  of  consumptives 
with  little  or  no  means  in  our  thickly  populated  States,  it  is  evi- 
dent that  the  existing  institutions  are  lilve  a  "  drop  of  relief  in  an 
ocean  of  woe."  Thus  let  us  hope  that  the  good  work  will  go  on, 
and  that  the  new  century  will  see  the  multiple  creation  of  State 
and  people's  sanatoria  in  the  United  States. 

That  such  special  institutions  and  thorough  hygienic  measures 
are  well  calculated  to  combat  tuberculosis  as  a  disease  of  the 
masses,  we  shall  try  to  prove  in  the  following  chapter. 


CHAPTEK  XXVI. 

What  Evidence  Exists  That  by  Taking  Care  of  Consump- 
tives IN  Special  Institutions  and  by  Hygienic  Meas- 
ures, Tuberculosis  as  a  Disease  of  the  Masses  can 
Eeally  be  Successfully  Combated  ? 

In  England  there  have  existed  special  institutions  for  the  treat- 
ment of  consumptives,  that  is  to  say,  hospitals  and  sea-coast  sana- 
toria, in  relatively  large  numbers,  for  over  fifty  years.     As  a  result 


AND   HOW   TO    COMBAT   IT. 


of  the  mainteiiance  of  these  institutions  and  the  enforcement  of  a 
most  excellent  general  public  hygiene,  it  was  possible  to  reduce 
the  mortality  from  tuberculosis  during  the  last  years  in  a  most 
surprising  manner,  and  more  rapidly  than  in  any  other  country  of 
the  world.  According  to  the  following  statistics,  compiled  by  Dr. 
Tatham,  the  statistical  superintendent  in  the  registrar-general's 
office,  the  mortality  from  tuberculosis  among  the  population  of 
England  and  Wales  has  been  reduced  to  wellnigh  half  of  that 
which  it  was  thii'ty  years  ago. 

The  death  rate  per  million  of  the  population  of  England  and 
Wales  from  pulmonary  tuberculosis  was  in — 


1870 2,410 

1875 2,202 

1880 1,869 

1885 1,770 

1890 1,682 


1893 1,468 

1894 1,385 

1895 1,398 

1896 1,307 


These  figures  are  perhaps  the  best  answer  to  the  question  asked 
at  the  head  of  this  chapter. 

CHAPTEE   XXVII. 

Can  the  Treatment  of  Consumption  be  Caeried  Out  with 
■  Satisfactory  Eesults  Outside  of  an  Institution  ? 

This  question,  too,  may  be  answered  in  the  affirmative,  for  the 
cure  of  a  consumptive  patient  is  certainly  also  possible  outside  of 
a  sanatorium.  The  conditions  essential  to  success  in  such  a  case 
are  that  the  social  position  of  the  patient  and  the  general  environ- 
ments are  such  that  all  the  hygienic  and  dietetic  measures,  so  es- 
sential in  the  modern  treatment  of  consumption,  are  at  the  disposal 
of  the  physician.  The  latter,  however,  though  he  may  be  well 
trained  and  exceedingly  skilful,  cannot  hope  for  success  unless 
the  patient  is  obedient  and  willing  to  carry  out  every  detail  of  the 
treatment. 

We  give  here  an  illustration  (Fig.  22)  of  how  the  patient  m  his 
own  house  may  arrange  for  permanent  open-an  treatment  by  build- 
ing a  small  addition  with  galleries  and  awnings  where  he  can  spend 
the  greater  part  of  the  day,  and  where  in  warmer  weather  he  may 
sleep  at  night.     Another  simple  method  for  carrying  out  the  rest 


Sanatorium 
at  Home. 


u 


TUBERCULOSIS   AS   A   DISEASE   OF   THE    MASSES 


cure  in  the  open  air  miglit  be  accomplished  in  the  following  man- 
ner :  A  large  beach  chair  of  wicker-work,  such  as  is  seen  at  our 
fashionable  sea-side  resorts,  is  procured.  After  the  seat  has  been 
removed  the  inner  walls  are  lined  with  padding.  A  reclining  chair 
is  placed  with  its  back  in  the  interior,  and  the  whole  arranged  so 
that  the  patient  is  protected  from  the  wind  and  sun.  There  the 
patient  installs  himself  for  the  day,  with  his  books  and  writ- 
ing materials  at  his  side  placed  on  a  little  table,  on  which  his 
meals  may  also  be  served.     Being  light,  the  whole  can  be  shifted 


l''i(i.  :J;J.— Arrangement  for  Open-Air  Treatment  at  Home. 

whenever  the  wind  changes  and  according  to  the  different  time  of 
day,  so  that  tiie  invalid's  body  may  be  bathed  by  the  rays  of  the 
sun,  while  his  liead  remains  in  the  shade  (Fig.  23). 

Poorer  patients,  who  for  financial  reasons  cannot  have  such  con- 
veniences and  who  cannot  be  received  in  a  sanatorium,  must  be 
advised  to  ask  the  help  of  a  physician,  and  under  his  guidance  imi- 
tate as  far  as  possible  and  practicable  the  sanatorium  instalment 
and  treatment  at  home.  During  the  day  the  lounge  or  reclining 
chair  should  be  moved  near  tlie  open  window  if  there  is  no  porch 
or  balcony.     In  summer,  or  on  not  too  cold  or  windy  days  in  wiu- 


AND   HOW   TO   COMBAT   IT. 


75 


ter,  the  patient  may  be  placed,  warmly  wrapped,  on  his  chair  on 
the  flat  roof,  protectmg  his  head  from  the  sun  by  an  umbrella  or  a 
small,  improvised  tent.  If  there  is  a  yard  or  garden,  a  small  plat- 
form of  boards  may  be  arranged  for  the  chair  in  a  spot  sheltered 
from  the  wind.  A  plain  steamer  chair,  padded  with  a  quilt  or 
blanket,  will  answer  the  pm-pose  just  as  well  as  a  costly  reclining 


Fig.  ~3.— Rest  Cure  at  Home. 


chair.     How  to  arrange  for  the  cold-water  treatment  at  home,  we 
have  already  described  on  page  34. 

The  hygienic  precautions  concerning  the  expectoration  must,  of 
course,  be  carried  out  in  the  private  home  as  rigorously  as  in  the 
institution.  Thus,  if  the  patient  has  an  earnest  determination  to 
do  his  duty,  confidence  in  his  physician,  and  the  good  will  of  the 
friends  and  relatives  who  live  with  him,  it  is  possible  to  make  even 
a  modest  home  temporarily  suitable  for  the  sanatorium  treatment. 


76 


TUBERCULOSIS   AS   A  DISEASE    OF   THE   MASSES 


CHAPTEE   XXVIII. 

What  can  Philanthropists  and  Other  Men  and  "Women  of 
Good  Will  Do  to  Help  Combat  Tuberculosis  as  a  Dis- 
ease OF  THE  Masses  ? 

In  Chapter  XXV.  we  have  spoken  of  the  most  urgent  need  of 
sanatoria  for  the  consumptive  poor.  These  institutions  are  par- 
ticularly wanted  in  large  centres  of  population.  In  nearly  all  of 
our  large  cities  there  are  thousands  of  poor  consumptives  living 
without  care  or  treatment  in  their  dark,  filthy  tenement-houses, 
and  spreading  their  disease  to  their  kin  and  neighbors.  Perhaps 
not  one  of  all  the  great  cities  of  the  Union  at  the  present  time  can 
offer  sufficient  hospital  facilities  for  the  treatment  or  isolation  of 
these  unfortunate  people.  A  very  large  percentage  of  these  pa- 
tients could  be  cured  or  restored  to  health  and  made  breadwinners 
of  theh  families  if  they  were  taken  away  from  their  unhygienic 
surroundings  in  time  and  received  proper  treatment  in  a  sana- 
torium. 

What  great  good  wealth  may  do  in  this  respect,  how  much  mis- 
ery and  sufieriug  it  may  alleviate,  and  how  many  lives  it  may  thus 
save,  needs  hardly  any  fm-ther  demonstration. 

But,  besides  the  sufferers  from  pulmonary  tuberculosis,  there  is  a 
large  class  of  sufferers,  especially  among  the  children  of  the  poorer 
classes,  who  are  afflicted  with  other  forms  of  tuberculous  disease, 
particularly  scrofula,  and  joint  and  bone  tuberculosis.  How  very 
prevalent  these  scrofulous  and  tuberculous  diseases  are  among  chil- 
dren people  in  general  have  scarcely  an  idea.  In  Berlin,  Ger- 
many, careful  statistics  are  kept  concerning  the  daily  attendance  of 
the  children  at  the  public  schools.  In  one  of  them  it  was  found 
that  out  of  125  boys  and  132  girls  who  did  not  attend  school 
regularly,  not  less  than  114  of  the  former  and  115  of  the  latter 
suffered  from  tuberculous  or  scrofulous  troubles. 

We  have  already  spoken  on  page  63  of  th  )  excelleut  result  ob- 
tained in  the  treatment  of  tuberculous  and  scrofulous  children  in 
the  sea-coast  sanatoria  of  France,  Germany,  Holland,  and  Italy. 
The  climate  at  the  sea-shore,  in  addition  to  good  nutrition  and  cold 


AND   HOW   TO   COMBAT  IT. 


7Y 


and  warm  sea-baths,  seems  to  ]je  particularly  favorable  for  the 
cure  of  scrofula  and  tuberculosis  in  children.  Institutions  for  this 
treatment,  like  sanatoria  for  consumptive  adults,  are  important 
factors  in  combating  tuberculosis  as  a  disease  of  the  masses. 
The  creation  of  such  institutions  in  our  own  country  cannot  be 
too  warmly  recommended  to  those  whoswish  to  help  suffering  little 
children. 

The  cure  of  tuberculosis  in  its  various  forms  can  be  accomplished 
only  by  a  thorough  hygienic  and  dietetic  treatment  under  strict 
medical  supervision,  in  sanatoria,  or,  if  ch-cumstances  permit,  at 
the  home  of  the  patient. 

The  prevention  of  tuberculosis  as  a  disease  of  the  masses,  on  the 
other  hand,  especially  in  the  form  of  pulmonary  tuberculosis  or 
consumption,  must  be  sought  in  combating  the  causes.  In  igno- 
rance, lack  of  light,  air,  and  sun,  unhealthy  tenements,  unclean 
linen,  lack  of  proper  or  sufficient  food,  excesses  of  all  kinds,  and, 
above  all,  in  the  abuse  of  alcoholic  beverages,  must  we  recognize 
to-day  the  most  important  factors  in  the  propagation  of  the  disease. 

To  combat  the  ignorance  in  regard  to  hygienic  modes  of  life  in 
general  and  the  hygiene  of  tuberculosis  in  particular,  among  the 
masses,  must  be  the  duty  of  the  educated.  Physicians,  teachers, 
employers,  and  all  men  and  women  who  have  time,  means,  talent, 
and  inclination,  should  unite  to  educate  the  masses  by  lectures  and 
the  distribution  of  pamphlets  concerning  the  natm-e  of  diseases, 
particularly  tuberculosis.  The  formation  of  societies  for  the  pre- 
vention of  tuberculosis  should  be  encouraged  in  every  State  of 
the  Union.  The  State  and  municipal  governments,  boards  of 
health,  or  other  sanitary  authorities  should  not  only  favor  these 
useful  enterprises,  but  gladly  co-operate  in  order  to  increase  their 
usefulness. 

To  give  to  the  poor  people  of  large  cities  more  air,  light,  and 
sun,  it  is  essential  not  only  to  provide  for  good  sanitary  dwellings, 
of  which  we  shall  speak  in  detail  in  the  next  chapter,  but  also 
to  create  a  number  of  parks  and  playgTounds,  by  public  means  or 
private  philanthropy,  particularly  in  the  more  densely  populated 
districts.  Such  parks  and  breathing  places  are  justly  called  the 
lungs  of  a  gi-eat  city. 


General 
Causes  of 
Tubercu- 
lous 
Diseases. 


78  TUBERCULOSIS   AS   A   DISEASE   OP   THE   MASSES 

Cleanliness  and  the  beneficent  influence  of  a  batli  must  be  prac- 
tically taught  to  the  ignorant.  While  it  would  be  deshable  that 
every  family  should  have  its  own  bathroom,  it  will  be  some 
time  yet  before  this  ideal  condition  will  be  obtained.  In  the 
Public  mean  time  the  establishment  of  a  number  of  public  baths,  of  which 
Baths.  we  made  mention  on  page  43  in  speaking  of  labor  colonies,  will  be 
one  of  the  best  means  to  improve  the  condition  of  the  poor  in  this 
respect  and  render  them  less  liable  to  disease.  As  an  example  of 
the  excellent  work  of  such  public  baths  I  give  an  extract  from 
the  report  of  the  New  York  People's  liath  of  last  year.  These 
baths  were  erected  and  are  mamtained  and  managed  by  the  Asso- 
ciation for  Improving  the  Condition  of  the  Poor:  "The  People's 
Baths  are  located  at  No.  9  Centre  Market  Place,  New  York.  They 
were  opened  in  August,  1891.  The  building  and  its  equipment 
have  cost  about  $28,000.  It  is  situated  on  land  for  which  no 
ground  rent  is  charged.  The  city  furnishes  the  water  free.  The 
building  is  constructed  of  enamelled  brick  and  iron,  and  contams 
twenty-six  baths,  twenty-three  of  which  are  spray  baths  (seventeen 
for  men  and  six  for  women).  The  other  three  baths  are  tubs  for 
old  women  and  children.  On  the  second  floor  are  living  cpiarters 
for  the  superintendent,  and  in  the  basement  the  steam  plant  and 
laundry.  The  cost  of  a  bath  is  five  cents,  which  includes  a  sepa- 
rate piece  of  soap  and  a  towel.  Last  year  (1899)  the  baths  sur- 
passed all  previous  records,  and  have  paid  their  operating  expenses. 
The  result  of  the  year's  work  shows  a  credit  balance  of 
$137.01.  The  total  number  of  bathers  was  120,347,  an  increase 
over  the  previous  fiscal  year  of  4,662.  AU  monthly  and  daily 
records  of  number  of  bathers  were  also  surpassed.  In  July  there 
were  17,452  bathers,  and  on  July  2 2d  the  number  was  1,175. 

"The  total  operating  expenses  were  $5,571.99,  and  the  total  re- 
ceipts $5,709.  No  more  interestmg  attempt  to  better  the  condi- 
tions under  which  the  tenement  population  live  has  ever  been 
made  than  the  People's. Baths.  Their  record  for  the  past  eight 
years  demonstrates  that  habits  of  cleanliness  can  be  instilled  into 
those  occupying  the  very  worst  cpiarters  of  the  city.  The  success 
of  the  baths  is  also  largely  due  to  the  fact  that  they  have  been 
conducted  strictly  on  a  business  basis,  the  patrons  feeling  that  they 


AND   HOW   TO   COMBAT  IT. 


79 


have  given  a  reasonable  equivalent  for  the  services  and  accommo- 
dations extended  them." 

Of  course,  these  establishments,  in  order  to  be  truly  useful, 
should  be  open  all  the  year  round,  all  day  and  in  the  evenings, 
and  to  men,  women,  and  children. 

The  causes  of  insufficient  and  bad  nutrition,  while  they  have 
often  to  be  sought  in  the  economical  and  social  condition  of  the 
community,  which  we  cannot  discuss  here,  are  just  as,  and  per- 
haps more,  fi'equently  to  be  found  in  ignorance  and  inexperience. 
To  make  a  good,  plain,  healthy,  and  tasty  meal  with  relatively 
little  expense  is  an  art  which  must  be  taught  to  the  young  wife, 
leaving  the  factory  or  the  position  in  the  store  to  enter  upon  the 
duties  of  a  housewife.  Here  is  a  field  for  noble-minded  and  ex- 
perienced women  who  have  made  the  art  of  cooking  a  study.  By 
imparting  their  experience  to  their  less  fortunate  sisters,  they  wiQ 
make  a  new  household  lastingly  happy. 

Of  course,  the  establishment  of  public  eating  houses,  where 
especially  the  unmarried  people  of  the  working  classes  can  obtain 
good  and  plain  meals  for  a  nominal  price,  is  also  a  necessity.  In 
connection  with  the  subject  of  malnutrition,  we  wish  to  say  one 
more  word  concerniug  poor  school-children,  especially  m  large 
cities.  The  majority  of  them  very  rarely  go  home  for  luncheon, 
and  the  provisions  they  bring  along  from  home  are  often  of  the 
most  meagre  kind.  In  some  cities  of  Germany  the  experiment 
has  been  made  to  provide  these  poor  children  with  a  lunch  of  good 
meat  sandwiches  and  a  glass  of  mük.  The  result  of  this  most 
praiseworthy  work  among  children  badly  fed  at  home  has  been 
simply  surprising.  Nearly  every  one  of  them  gained  in  weight 
within  a  month's  time,  and  all  of  them  were  certainly  made  hap- 
pier and  capable  of  doing  better  work  at  school. 

Now  one  more  word  concerning  alcoholism  or  drunkenness. 
There  is  no  doubt  that  alcoholism  must  be  considered  the  gi-eatest 
enemy  of  the  welfare  of  a  nation,  the  most  fi-equent  destroyer  of 
family  happiness,  the  ruination  of  mind,  body,  and  soul,  and  cer- 
tainly the  most  active  co-operator  of  the  deadly  tubercle  bacillus  or 
germ  of  tuberculosis  (consumption). 

To  combat  alcoholism  (drunkenness  or  intemperance)  requii'es 


80  TUBERCULOSIS   AS  A  DISEASE   OF  THE   MASSES 

above  all  education.  Extreme  prosecution  and  fanatical  laws  will 
do  little  good.  From  early  childhood  the  dangers  of  intemperance 
and  its  fearful  consequences  should  be  taught.  In  schools  and  at 
home  the  drunkard  should  be  pictured  as  the  most  unhappy  of  all 
mortals.  While  the  very  moderate  use  of  feebly  alcoholic  drinks, 
such  as  light  beers,  may  be  considered  as  harmless  to  adults  when 
taken  with  their  meals,  alcohol  should  never  be  given  to  children 
even  in  the  smallest  quantities. 

In  families  in  which  there  is  a  fear  of  hereditary  transmission 
of  the  deshe  for  strong  drink,  even  the  mildest  alcoholic  drinks 
should  be  absolutely  avoided.  It  would  also  be  best  if  all  people 
so  predisposed,  or  who  may  have  acquired  only  the  occasional  de- 
sire for  drink,  would  never  smoke,  for  experience  has  taught  that 
attacks  of  dipsomania  (periodical  sprees)  are  often  caused  by  an 
excessive  use  of  tobacco.  The  young  man  starting  out  in  life 
should  take  with  him  the  moral  training  which  will  enable  him 
to  be  a  gentleman,  and  be  considered  a  polite  gentleman,  though 
he  absolutely  refuses  ever  to  enter  a  liquor  saloon  m  order  to  treat 
or  be  treated  to  drink.  It  is  this  treating  habit — alas !  so  prevalent 
in  our  American  society — which  has  ruined  many  a  young  man 
and  made  him  a  moral  and  physical  wreck.  The  creation  of  tea 
and  coffee  houses  where  warm,  non-alcoholic  drinks  including 
bouillon  are  sold  in  winter  and  cool  ones  in  summer,  are  to  be 
encouraged.  It  would  be  of  additional  advantage  if  some  of  these 
houses  could  also  offer  healthful  amusements  for  old  and  young. 
Temperance  societies,  which  through  intelligent  propaganda  help 
to  combat  the  fearful  evü  of  alcoholism,  should  receive  encourage- 
ment from  everybody. 

CHAPTEE   XXIX. 

How  Might  the  Tuberculosis  Problem  in  the  United  States 
BE  Solved  by  Judicious  Legislation  and  a  Combination 
of  Public  and  Private  Philanthropy? 

Presuming  that  there  were  in  all  the  States  sufficient  regulations 
against  the  spread  of  tuberculosis  from  man  to  man,  and  that  the 
laws  against  the  propagaticm  of  tuberculosis  by  animals  were  uni- 


AND  HOW  TO   COMBAT  IT.  81 

form  throughout  the  United  States  and  enforced  in  the  best  pos- 
sible manner,  we  would,  for  further  work,  suggest  the  following 
plan,  more  particularly  for  the  larger  centres  of  population : 

Just  as  there  exists  in  nearly  all  states  or  municipalities  a  com- 
mission or  a  number  of  special  examiners  for  the  purpose  of  deter- 
mining who  is  a  proper  subject  for  .state  care  in  an  asylum  for  the 
insane,  so  should  there  exist  a  commission  for  the  determination 
of  admission  to  a  municipal  or  state  mstitution  for  consumptives. 
Such  a  commission,  composed  of  a  certain  number  of  general  prac- 
titioners and  health  officers,  should  be  aided  in  its  work  by  the 
charity  organizations.  Each  case  should  be  investigated  by  a  com- 
bined committee  of  physicians  and  laymen,  for  the  following  pur- 
poses : 

1.  To  determine  the  applicant's  condition  by  a  medical  exami- 
nation. 

2.  To  visit  his  home  if  he  has  been  found  tuberculous,  and  to 
institute  such  hygienic  measures  as  seem  necessary  (distribution  of 
pocket  spittoons,  disinfectants,  etc.,  gratuitously  if  the  patient  is 
poor). 

3.  To  examine  the  other  members  of  the  family,  in  order  to  find 
out  if  any  of  them  have  also  contracted  the  disease,  and,  if  so,  to 
counsel  proper  treatment. 

4.  To  report  in  full  to  the  sanitary  authorities  concerning  the 
condition  of  the  patient's  dwelling.  Its  renovation  or  even  de- 
struction may  be  imperative  when  it  is  evident  that  tuberculosis 
has  become  "  endemic  "  there,  owing  to  the  condition  of  the  soil 
or  to  other  sanitary  defects. 

5.  To  determine  the  financial  condition,  whether  the  patient  is 
or  is  not  able  to  pay,  and  whether  or  not  by  his  being  taken  to  an 
institution  the  family  will  become  destitute. 

If  the  latter  should  be  the  case,  it  would  be  necessary  for  the 
municipality  to  provide  for  the  famuy.  In  many  cases  a  letter  of 
inquiry,  sent  to  the  former  medical  attendant  of  the  patient,  would 
materially  aid  the  work  of  the  investigation  committee. 

Any  individual  should  have  the  right  to  present  himself  for  ex- 
amination, and  every  physician  should  be  at  liberty  to  recommend 
any  person  for  examination  to  the  board  of  his  precinct  or  district. 


82  TUBERCULOSIS  AS  A  DISEASE   OF  THE   MASSES 

The  institutions  needed  to  carry  out  this  plan  would  be : 

1.  A  centrally  located  reception  hospital  and  dispensary.  The 
dispensary  should  treat  the  ambiilant  tuberculous  patients,  whose 
admission  into  the  sanatorium  is  impracticable  or  has  to  be  delayed 
for  want  of  room.  These  dispensaries  should  also  serve  the  pa- 
tient discharged  fi-om  the  sanatorium  as  a  place  to  seek  counsel, 
and  thus  aid  in  his  continued  improvement  and  guard  against  the 
possibility  of  a  relapse. 

2.  One  or  several  city  sanatoria,  located  in  the  outskirts,  and  if 
possible  in  a  somewhat  elevated  region,  where  the  atmosphere  is 
known  to  be  pure.  Here  all  patients  should  pass  through  a  pre- 
paratory sojourn  before  being  sent  to  the  mountain  sanatorium. 
The  more  advanced  cases  would  all  be  retained  here. 

3.  One  or  several  mountain  sanatoria  at  no  greater  distance  from 
the  city  than  from  three  to  five  hours  by  raü,  at  an  altitude,  if 
possible,  of  between  one  thousand  and  two  thousand  feet,  on  porous 
ground,  with  southern  exposure,  as  nearly  as  possible  protected  from 
the  coldest  winds  by  higher  mountains,  and  preferably  surrounded 
by  a  pine  forest.  A  farm  in  the  vicinity,  where  the  thoroughly 
convalescent  patients  could  do  light  work,  might  make  the  institu- 
tion in  a  measure  self-supporting.  To  this  place  the  selected  in- 
cipient and  the  improved  cases  from  the  city  sanatorium  should 
be  sent  to  complete  their  cure.  To  the  mountain  sanatorium 
there  should  also  be  attached  a  department  for  children  suffering 
from  pulmonary  tuberculosis. 

4.  Several  sea-side  sanatoria  for  the  treatment  of  childi-en 
afflicted  with  tuberculous  diseases  of  the  joints  and  other  tubercu- 
lous (scrofulous)  manifestations. 

5.  A  maternity  sanatorium  where  tuberculous  mothers  should 
be  received  a  few  months  previous  to  their  confinement,  and  sur- 
rounded by  the  best  hygienic  and  dietetic  care.  They  should  also 
remain  in  the  sanatorium  for  some  time  after  childbirth.  It  is 
only  by  taking  away  these  mothers  from  their  unsanitary  tenement 
homes,  and  placing  them  under  constant  medical  supervision  in 
such  an  institution,  some  time  before  and  after  their  confinement, 
that  the  fearful  mortality  among  tuberculous  mothers  after  child- 
birth can  be  reduced. 


AND   HOW  TO   COMBAT   IT. 


83 


The  beneficial  effect  on  the  woman's  and  child's  constitutions 
through  such  an  an-angement  can  hardly  be  over-estimated.  Leav- 
ing aside  the  physical  well-beiug  thus  largely  assured  to  mother 
and  child  at  a  period  when  theii-  organisms  need  the  most  tender 
care,  the  hygienic  training  which  the  mother  will  have  received  in 
such  an  institution  will  be  of  lasting  utility  to  herself  and  child, 
to  the  family,  and  to  the  community. 

These  maternity  sanatoria  need  not  be  situated  at  a  great  dis- 
stance  from  the  city.  All  that  would  be  essential  is  that  they 
should  be  erected  on  good,  porous  gi'ound,  preferably  somewhat  ele- 
vated, and  in  a  locality  where  the  atmosphere  is  as  pure  as  possi- 
ble. The  buildings  should  be  constructed  according  to  the  re- 
quirements of  modern  ways  of  treating  women  in  childbirth,  and 
with  ample  facilities  for  rest  cures,  sun  baths,  and  the  other  equip- 
ments of  a  sanatorium  for  tuberculous  invalids. 

Another  important  work  toward  the  solution  of  the  tuberculosis 
problem  which  might  be  accomplished  by  a  combination  of  public 
and  private  philanthropy,  in  addition  to  legislative  measures,  is 
the  multiple  creation  of  model  tenement  houses,  particularly  in 
large  centres  of  population.  There  should  everywhere  be  legisla- 
tion to  make  the  erection  of  any  but  model  tenement  houses 
impossible,  and  the  law  should  at  the  same  time  empower  the 
sanitary  au thorites  to  inspect  all  existing  tenements,  and  if  there 
are  any  which  are  unfit  or  unsafe  for  human  habitation  owing  to 
lack  of  air,  light,  or  ventilation,  they  should  be  condenmed.  As 
has  been  said  before,  if  a  thorough  renovation  will  not  make  them 
sanitary,  to  tear  them  down  will  be  the  only  remedy. 

Overcrowding  in  tenement  houses  should  be  considered  a  crime, 
and  the  owner  should  be  held  responsible  for  it.  A  family  of  fi'om 
six  to  ten  living  in  three  rooms,  of  which  perhaps  only  one  receives 
direct  light  and  air,  cannot  possibly  remain  in  a  good  state  of  health 
for  any  length  of  time.  It  is  the  dreary  and  cheerless  room  of  the 
tenement  dwelling  which  often  drives  the  wage  earner  to  the 
saloon.  He  finds  light  and  life  in  the  saloon  and  becomes  indiffer- 
ent to  home  conditions.  Give  the  workingman  a  pleasant,  clean, 
healthy,  and  comfortable  home,  and  the  rumshop  will  have  less 
attraction  for  him.     He  will  be  a  better  husband,  father,  and  citi- 


Maternity 
Sanatoria. 


Tenements 
and 

Tuberculo- 
sis. 


Houses,  etc. 


84  fUBERCtJLOSiS  AS  A  DISEASE   OF  THE  MASSES 

zen.  The  money  formerly  spent  for  liquor  will  go  to  the  butcher 
and  baker  for  the  better  nutrition  of  his  family,  and  underfeeding 
(another  important  agent  iu  preparing  the  field  for  tuberculous  dis- 
eases) will  be  materially  lessened.  A  very  praiseworthy  move- 
ment in  this  direction  was  recently  inaugurated  m  New  York  by 
the  creation  of  a  tenement-house  commission,  which  has  for  its 
purpose  the  improvement  of  the  housing  of  the  poor  by  the  crea- 
tion and  enforcement  of  better  tenement  laws. 

Overcrowded  prisons,  asylums,  almshouses,  schools,  barracks, 
public  homes,  lodging  houses,  etc.,  must  also  receive  the  attention 

Overcrowtt-  ^^  ^■^^  sanitary  authorities.     The  often  crowded  and  unclean  sauors' 
ing  of  "^ 

Prisons       boarding  houses  must  not  be  overlooked.     Enough  cubic  space  per 

Asylums,     individual,  more  systematic  ventilation,  and  the  isolation  of  tuber- 
^Lodging      culous  invalids  are  the  remedies  which  must  be  applied. 

Ship-builders,  ship-owners,  and  captains  should  bear  in  mind 
that  the  intensely  crowded  quarters  to  which  the  average  sailor  is 
confined  during  his  hours  of  rest  and  sleep  are  absolutely  detri- 
mental, and  even  the  outdoor  life  during  the  hours  of  work  cannot 
counteract  the  deleterious  influence  which  the  vitiated  ah  of  the 
forecastle  exerts  on  the  health  of  the  seaman.  Of  course,  we  are 
aware  that  the  space  given  to  each  individual  on  board  ship  must 
be,  of  necessity,  limited;  still  there  can  be  some  improvement, 
and  the  ventilation  can  be  made  more  perfect.  For  the  very  rea- 
son that  sailors  have  to  live  in  crowded  quarters  the  danger 
of  infection  on  board  ship  is  very  great.  A  tuberculous  sailor 
still  at  work  is  almost  certain  to  infect  his  comrades.  But  ship- 
board is  not  the  only  place  where  sailors  are  exposed  to  the  dis- 
ease. Wlien  on  shore  they  mostly  frequent  and  sleep  in  houses 
where  the  accommodations  consist  of  bunks  and  straw,  and  where 
sanitation  is  so  neglected  that  they  are  in  stul  greater  danger  of 
contracting  disease.  To  prevent  the  spread  of  infection  among 
sauors  there  is  but  one  remedy,  and  that  is  the  regular  periodic 
examination  of  every  sauor  on  board  ship  and  the  exclusion  from 
service  of  mdividuals  suffering  from  pulmonary  tuberculosis. 

Lastly,  the  physicians,  statesmen,  and  philanthropists  interested 
in  the  solution  of  the  tuberculosis  problem  have,  besides  working 
for  the  better  housing  of  the  poor  and  the  creation  of  special  insti- 


AND  HOW   TO   COMBAT   IT.  85 

tutions  for  the  treatment  of  consumptives,  an  additional  mission  ^  .  ^i 
to  perform.  The  tide  of  emigration  from  village  to  city  should  be  fpom  City  to 
reversed.  If  tuberculosis  has  made  its  appearance  in  a  family  liv-  Country. 
iug  in  a  large  city,  the  physician  should  exert  aU  his  influence  to 
induce  especially  the  younger  members  to  migrate  to  the  country 
and  seek  outdoor  occupations.  Statesmen  should  protect  the  in- 
terests of  the  farmer,  so  that  farming  will  have  more  attraction  to 
the  rising  generation  than  it  has  had  in  the  last  few  decades ;  and 
})hilanthropists  should  aid  the  statesmen  by  endowing  institutions 
for  instruction  in  scientific  and  profitable  agriculture,  and  also  by 
providing  healthful  amusements,  good  libraries,  and  other  educa- 
tional institutions  in  country  districts,  thus  making  living  outside 
of  large  cities  more  interesting  and  attractive  to  young  people ;  in 
short,  the  love  of  nature  and  life  in  the  open  air  should  be  more 
cultivated.  In  the  proportion  in  which  this  is  done  tuberculosis 
wiU  decrease.  ^  ^^^  "^.^e 

The  creation  of  schools  of  forestry  in  connection  with  the  preser- 
vation and  cultivation  of  forests  in  many  States  where  a  wasteful 
destruction  of  trees  is  now  carried  on,  would  give  useful  and 
healthful  employment  to  a  number  of  people,  as  weU.  as  render  the 
region  more  healthful.  It  would  offer  attractive  careers  to  young 
men  seeking  to  overcome  hereditary  or  acquired  tendencies  to  tu- 
berculous diseases.  ^ 

CHAPTER  XXX. 

Conclusions. 

The  author  of  this  essay  is  aware  that  much  that  has  been  asked 
in  the  preceding  pages  may  appear  at  first  too  difiicult  to  be  realized ; 
nevertheless,  he  is  convinced  that  by  the  earnest  co-operation  of  all 
interested  in  the  solution  of  the  various  problems,  the  task  will 
prove  far  easier  than  might  be  anticipated.  In  view  of  the  great 
mortality  and  fearful  ravages  of  the  disease  in  question,  his  hopes 
for  a  more  rigorous  crusade  against  this  common  foe  of  all  mankind 
are  justified.  He  is  optimistic  enough  to  believe  even  in  an  ulti- 
mate eradication  of  the  disease. 

If  any  community  is  visited  by  an  acute  contagious  disease, 


86  TUBERCULOSIS   AS   A  DISEASE  OF   THE   MASSES. 

smallpox  for  example,  of  which  a  few  people  may  die,  everybody 
is  up  in  arms ;  while  consumption,  a  far  more  prevalent  disease, 
demanding  thousands  of  lives  every  year,  is  treated  wellnigh  with 
indifference.  Yet  all  who  have  made  the  disease  a  study  have  for 
years  come  to  the  conclusion  that  tuberculosis,  especially  in  its 
pulmonary  form,  is  not  only  a  preventable  disease,  but  one  which 
can  Ü1  the  majority  of  cases  be  completely  and  lastingly  cured.  It 
is  certainly  within  the  power  of  man,  living  in  a  civilized  country, 
such  as  the  United  States,  where  so  much  intelligence,  wealth, 
prosperity,  and  philanthropy  prevail,  to  combat  tuberculosis  as  a 
disease  of  the  masses  most  successfully. 

All  that  is  required  to  attain  this  goal  is  the  combined  action 
of  a  wise  government,  well-trained  physicians,  and  an  intelligent 
people. 


SUPPLEMENT. 


Home  Hygiene  to  Prevent  Tuberculosis. 


Tuberculosis  may  be  called  a  dust  and  indoor  disease.  Tht 
less  dust,  the  less  tuberculosis.  The  less  people  live  in  an  indoor  at- 
mosphere, the  less  are  they  liable  to  contract  this  disease. 

How  may  the  danger  arising  from  dusting  and  sweeping  be  re- 
duced to  a  minimum?  To  answer  this  question  I  cannot  do  better 
than  to  reproduce  the  excellent  rules  which  were  suggested  to  our 
New  York  Committee  on  the  Prevention  of  Tuberculosis,  by  the 
distinguished  Prof.  T.  Mitchell  Prudden,  of  Columbia  University. 


Tuberculo- 
sis an  In- 
door 
Disease. 


Sweeping  and  Dusting. 


"  When  you  sweep  a  room,  raise  as  little  dust  as  possible,  because 
this  dust  when  breathed  irritates  the  nose  and  throat  and  may  set 
up  catarrh.  Some  of  the  dust  breathed  in  dusty  air  reaches  the 
lungs,  making  parts  of  them  black  and  hard  and  useless. 

"  If  the  dust  in  the  air  you  breathe  contains  germs  of  consump- 
tion (tubercle  bacilli),  which  have  come  from  consumptives  spitting 
on  the  floors,  you  run  the  risk  of  getting  consumption  yourself.  If 
consumptives  use  proper  spit-cups  and  are  careful  in  coughing  or 
sneezing  to  hold  the  hand  or  handkerchief  over  the  nose  and  mouth 
so  as  not  to  scatter  spittle  about  in  the  air,  the  risk  of  getting  the 
disease  by  living  in  the  same  room  is  mostly  removed." 

"  To  prevent  making  a  great  dust  in  sweeping,  use  moist  sawdust 
on  bare  floors.  When  the  room  is  carpeted,  moisten  a  newspaper 
and  tear  it  into  small  scraps  and  scatter  these  over  the  carpet  when 
you  begin  sweeping.  As  you  sweep,  brush  the  papers  along  by  the 
broom  and  they  will  catch  most  of  the  dust  and  hold  it  fast,  just 
as  the  sawdust  does  on  bare  floors.  Do  not  have  either  the  paper 
or  the  sawdust  dripping  wet,  only  moist. 

"In  dusting  a  room,  do  not  use  a  feather  duster;  because  this 


How  to 

Sweep 

Without 

Raising 

Dust. 


88 


TUBERCULOSIS   AS   A   DISEASE   OP   THE   MASSES 


does  not  remove  the  dust  from  the  room,  but  only  brushes  it  into 
the  air  so  that  you  breathe  it  in;  or  it  settles  down  and  then  you 
have  to  do  the  work  over  again. 

"  Use  soft,  dry  cloths  to  dust  with,  and  shake  them  frequently 
out  of  the  window;  or  use  slightly  moistened  cloths,  and  rinse 
them  out  in  water  when  you  have  finished.  In  this  way  you  get 
the  dust  out  of  the  room." 

"  In  cleaning  rooms  you  should  remember  that  dust  settles  upon 
the  floors  as  well  as  on  the  furniture,  and  is  stirred  into  the  air  we 
breathe  by  walking  over  them.  You  can  easily  remove  all  this 
dust  in  rooms  which  have  bare  floors,  in  houses,  stores,  shops, 
schoolrooms,  etc.,  after  the  dust  has  settled,  by  passing  over  the 
floor  a  mop  which  has  been  wrung  out  so  as  to  only  be  moist,  but 
not  dripping  wet." 


Thus  we  should  clean  our  homes  until  the  time  comes  when  not 
only  factories,  public  buildings,  hotels,  and  schoolhouses,  but  also 
the  homes  of  ordinary  citizens,  including  the  tenement-houses,  can 
be  cleaned  by  the  hygienic  pneumati-c  or  vacuum  cleaning  process. 

How  may  the  air  in  our  homes  be  rendered  as  fresh,  pure,  and 
sanitary  as  possible?  In  sunmier  this  problem  is  relatively  easy. 
The  windows  and  doors  can  be  left  open  so  as  to  make  the  air  as 
fresh  as  that  outside.  The  greatest  difficulty  is  experienced  in 
winter.  The  windows  cannot  be  left  open  all  the  time  then,  but 
the  rooms  should  be  thoroughly  and  frequently  aired  whether  there 
is  sickness  or  not.  I  have  already  referred  in  Chapter  XII.,  page 
39,  to  the  unwholesome  custom  of  heating  our  American  dwellings 
altogether  too  much  and  producing  thereby  too  dry  an  atmosphere. 

Experience  has  proven  that  we  can  be  perfectly  comfortable  in 
a  temperature  of  65°  F.  and  even  a  little  lower,  provided  that  the 
relative  percentage  of  moisture  is  60.  If  this  moisture  falls  to  30 
or  to  20  per  cent,  then  the  dry  throat,  dry  nose,  and  dry  skin  are 
in  evidence.  The  explanation  is  simple.  The  dry  air  absorbs 
the  moisture  from  the  body  and  causes  discomfort.  The  drying 
of  mucous  membrances  in  this  way  lays  them  open  to  the  invasion 
of  the  organisms  causing  colds,  gri]:)pe,  jmeumonia,  and  tubercu- 
losis. On  page  39,  Cha])ter  XII.,  I  have  illustrated  an  ap|)aratus 
called  a  "humidifier,"  and  suggested  various  other  ways  to  render 
the  atmosphere  moist  enough  to  be  sanitary.  I  reproduce  here  an 
instrument  whi(;h  will  be  helpful  in  determining  the  relative  humid- 


AND   HOW  TO   COMBAT   IT. 


89 


Fig.   24. — Direct    Reading   Hair- 
Hygrometer. 


ity.     It   has  been  strongly   recommended   by  the   Indiana  State 
Board  of  Health,  which  jjubhshed  it  with  the  following  description 
in  its  monthly  bulletin  under  the  name  of  Direct  Reading  Hair- 
Hygrometer.     Fig.    24   is    a    picture 
of  a  direct  reading  hair-hygrometer. 
Every   household,  every  schoolroom, 
and  every  workroom  should  have  one 
of  these  instruments,  for  it  is  a  fact 
that  the  humidity  of  the  air  is  of  more 
importance    than     the    tempera  uure 
This  hygrometer  is  not  absolutely  ac- 
curate, but  is  sufficiently  so  for  practi- 
cal   purposes.     Indeed,  it  is  as  accu- 
rate as  the  ordinary  thermometer.     If 
the  matter  of  humidity  was  carefully 
attended  to  by  every  one,  there  would 
be    a    decided    improvement   in   the 
general  health  and  a  very  great  less- 
ening of  diseases  of  the  air  passages. 

In  Chapter  IV.,  directions  concerning  the  disinfection  of  rooms, 
furniture,  wearing  apparel,  etc.,  used  by  a  consumptive  have  been 
explicitly  given.  To  secure  absolute  certainty  we  would  add  that 
after  every  disinfection,  be  it  for  tuberculosis  or  for  disease  pre- 
disposing to  tuberculosis  such  as  measles,  scarlet  fever,  whooping 
cough,  epidemic  grippe,  diphtheria,  smallpox,  pneumonia  or 
typhoid  fever,  a  thorough  airing  and  scrubbing  with  soap  and 
water,  of  floor,  walls,  furniture,  and  wearing  apparel  are  absolutely 
essential.  If  the  walls  are  papered  and  do  not  permit  a  thorough 
washing  they  should  be  repapered.  By  thorough  disinfection 
followed  by  an  equally  thorough  cleaning  and  airing  home  hygiene 
can  be  made  a  real  barrier  to  the  spread  of  many  infectious  diseases. 
Lastly  filtering  or  boiling  all  ordinary  drinking  water  will  serve  as 
additional  preventative. 

School  Hygiene  as  a  Factor  in  the  Prevention 
OF  Tuberculosis. 

The  school  board,  or  board  of  education  as  it  is  called  in  some 
localities,  in  choosing  a  site  for  a  school  should  bear  in  mind  that 
the  most  suitable  locality  is  a  somewhat  elevated  region,  where  the 
streets  are  wide  and  the  surrounding  houses  not  too  high  and  not 


Disinfec- 
tion, Scrub- 
bing, and 
Airing. 
Pure 
Drinking 
Water. 


90 


TUBERCULOSIS  AS  A  DISEASE   OF   THE   MASSES 


Law  in  the 

State  of 
New  York 
Concerning" 
Construc- 
tion of 
School- 
honses. 


Play- 
grounds 
and  Roof- 
gardens. 


too  close  together,  and  where  the  traffic  is  not  too  heavy.  About 
the  construction  of  a  modern  and  model  schoolhouse  much  could 
be  said.  The  essentials  of  such  construction  are  well  known  to  all 
sanitarians  and  up-to-date  architects,  still  in  the  interest  of  the 
cause  I  may  be  permitted  to  quote  here  a  portion  of  a  law  which 
has  recently  been  enacted  in  the  Legislature  of  New  York  in  refer- 
ence to  sanitation  of  schoolhouses.  "  No  schoolhouse  shall  here- 
after be  erected  in  any  city  of  the  third  class  or  in  any  incorporate 
village  or  school  district  of  this  State,  and  no  addition  to  a  school 
building  in  any  such  place  shall  hereafter  be  erected,  the  cost  of 
which  shall  exceed  five  hundred  dollars,  until  the  plans  and  specifi- 
cations for  the  same  shall  have  been  submitted  to  the  commissioner 
of  education  and  his  approval  endorsed  thereon.  Such  plans  and 
specifications  shall  show  in  detail  the  ventilation,  heating,  and 
lighting  of  such  buildings.  Such  commissioners  of  education  shall 
not  approve  any  plans  for  the  erection  of  any  school  building  or 
addition  thereto  unless  the  same  shall  provide  at  least  fifteen 
square  feet  of  floor  space  and  two  hundred  cubic  feet  of  air  space 
for  each  pupil  to  be  accommodated  in  each  study  or  recitation  room 
therein,  and  no  such  plans  shall  be  approved  by  him  unless  pro- 
vision is  made  therein  for  assuring  at  least  thirty  cubic  feet  of 
pure  air  every  minute  per  pupil,  and  the  facilities  for  exhaustion 
of  the  foul  or  vitiated  air  therein  shall  be  positive  and  independent 
of  atmospheric  changes.  ...  All  schoolhouses  for  which  plans 
and  detailed  statements  shall  be  filed  and  approved,  as  required 
by  this  act,  shall  have  all  halls,  doors,  stairways,  seats,  passageways, 
and  aisles,  and  all  lighting  and  heating  appliances  and  apparatus, 
arranged  to  facilitate  egress  in  case  of  fire  or  accident,  and  to  afford 
the  requisite  and  proper  accommodations  for  public  protection  in 
such  cases.  All  exit  doors  shall  open  outwardly  and  shall,  if  double 
doors  be  used,  be  fastened  with  movable  bolts  operated  simul- 
taneously by  one  handle  from  the  inner  face  of  the  door.  No 
staircase  shall  be  constructed  with  winding  steps  in  lieu  of  a  plat- 
form, but  shall  be  constructed  with  straight  runs,  changes  in  direc- 
tion being  made  by  platforms.  No  door  shall  open  immediately 
upon  a  flight  of  stairs,  but  a  landing  at  least  the  width  of  the  door 
shall  be  provided  between  such  stairs  and  such  doorways." 

In  relation  to  the  prevention  of  tuberculosis  I  would  suggest 
only  a  few  points.  Where  the  site  or  locality  does  not  permit  of 
having  a  large  playground,  a  roof-garden  which  can  be  covered  in 


AND   HOW   TO   COMBAT   IT. 


91 


winter  is  absolutely  necessary.  Instead  of  our  American  windows, 
which  can  only  be  opened  to  one-half  of  their  extent,  I  should 
wish  to  see  French  or  casement  windows  in  every  schoolhouse,or  win- 
dows sliding  into  the  wall,  or  those  that  turn  on  a  pivot,  all  of 
which  permit  twice  the  amount  of  foul  air  to  go  out  and  of  good  air 
to  come  in  that  our  ordinary  windows  do.  Heating  and  general  ven- 
tilation of  schoolrooms  should,  of  course,  be  of  the  most  improved 
kind.  The  walls  and  woodwork  of  schoolrooms  should  be  plain,  to 
make  the  accumulation  of  dust  virtually  impossible  and  the  cleaning 
easy.  All  corners  should  be  rounded  off,  and  the  walls  painted 
with  oil  paint.  The  interior  equipment — that  is  to  say,  the  school 
furniture,  benches,  and  desks — should  be  so  arranged  that  they 
can  easily  be  moved  or  folded  together,  so  that  a  thorough  cleaning 
of  the  floors  is  made  possible  after  each  daily  session.  It  goes 
without  saying  that  the  drinking-cup  should  be  replaced  by  the 
hygienic  drinking-fountain,  which  makes  the  use  of  a  cup  unneces- 
sary, and  thus  eliminates  one  method  of  transmission  of  microbic 
disease. 

Every  public  school  should  have  a  well-equipped  gymnasium, 
and  a  swimming-tank  with  constantly  running  fresh  or  salt  water, 
warmed  to  a  suitable  temperature  in  winter.  Each  pupil  should 
be  given  the  opportunity  to  bathe  several  times  during  the  week. 
To  learn  to  swim  should  be  made  obligatory,  and  every  class  should 
be  supervised  by  a  competent  swimming  master. 

I  am  convinced  that  the  public  school  which  has  a  well-equipped 
swimming  establishment  and  which  makes  regular  bathing  and  in- 
struction in  swimming  obligatory  for  every  pupil  will  not  only  have 
fewer  cases  of  infectious  and  contagious  diseases,  particularly  scrof- 
ula and  tuberculosis,  but  that  the  intellectual  and  moral  status 
of  its  pupils  will  be  higher. 

The  duties  of  the  superintendent  of  a  public  school  in  the  pre- 
vention of  tuberculosis  are  manifold.  In  arranging  the  curriculum 
he  should  bear  in  mind  never  to  push  the  intellectual  training  to 
the  detriment  of  the  bodily  development  or  physical  welfare  of  the 
children  in  his  school.  There  has  been,  and  is  yet,  altogether  too 
much  overtaxing  of  the  brain  and  the  nervous  system  of  our  boys 
and  girls  in  public  and  also  in  private  schools. 

The  physician  who  has  studied  closely  the  beginning  of  tuber- 
culous diseases  knows  that  it  is  often  at  the  period  of  entering 
puberty  that  the  predisposed  individual  becomes  most  susceptible 


Internal 
Equipment 
of  School- 
rooms. 


Sanitary 

Drinking 

Fountains. 


Gymnasi- 
um and 

Swimming 
Tank. 


Curriculum 
Should  be 
Suited  to 
Proper 
Mental  and 
Physical 
Develop- 
ment. 


92  TUBERCULOSIS  AS  A   DISEASE   OF  THE  MASSES 

to  the  invasion  of  the  bacillus,  particularly  when  additional  strain 
is  put  upon  the  physical  or  mental  system.  This  holds  good  of 
both  sexes.  A  judiciously  divided  curriculum,  interspersed  with 
gymnastics,  swimming,  and  as  much  outdoor  instruction  as  possible, 
would  seem  to  me  a  most  important  factor  in  the  prevention,  not 
only  of  tuberculosis,  but  of  all  indoor  diseases  and  even  nervous 
troubles. 
0  tdnnr  "^^  outdoor  instruction  I  mean  not  only  botanizing  tours  and 

Instruction,  geological  excursions,  but  also  outdoor  singing  and  outdoor  recita- 
tion. I  am  convinced  that  outdoor  singing  and  recitation,  when  the 
weather  is  neither  too  windy  nor  too  cold,  are  most  excellent  means 
to  prevent  the  development  of  pulmonary  diseases.  Breathing 
exercises,  such  as  are  described  in  Chapter  jXII.  of  this  book  should 
of  course  be  instituted  at  least  for  a  few  minutes  at  a  time  every 
hour  or  two.  The  lessons  in  physiology  and  hygiene  at  school 
must  be  adapted  to  the  age  and  understanding  of  the  pupils.  The 
teacher  should,  of  course,  be  familiar  with  all  the  practical  and 
feasible  methods  in  vogue  in  regard  to  the  prevention  of  tubercu- 
losis as  an  infectious  and  communicable  disease.  The  source  of 
infection  from  indiscriminate  expectoration,  from  coughing  and 
sneezmg  in  people's  faces,  from  kissing  on  the  mouth,  and  other 
unhygienic  habits  can  be  taught  in  simple  words  to  the  children 
of  even  the  primary  classes.  A  good  method  to  impress  these 
simple  rules  on  school  children,  and  thus  prevent  them  from  con- 
tracting tuberculosis  during  school  life,  is  to  have  a  printed  leaflet 
given  to  each  child.  These  leaflets  should  contain  the  do's  and 
don'ts  which  are  the  aiphabet  in  the  prevention  of  tuberculosis  in 
kindergartens,  private  and  public  schools,  and  colleges.  For  this 
purpose  I  have  compiled  the  following: 

Simple  Rules  for  School  Children  to  Prevent  Tuberculosis. 

Every  child  and  adult  can  help  to  fight  consumption.  School 
children  can  be  helpful  by  complying  with  the  following  rules: 

Do  not  spit  except  in  a  spittoon,  a  piece  of  cloth,  or  a  handker- 
chief used  for  that  pur})ose  alone.  On  your  return  home  have  the 
cloth  burned  by  your  mother,  or  the  handkerchief  put  in  water 
until  ready  for  the  wash. 

Never  spit  on  a  slate,  floor,  playground,  or  sidewalk. 

Do  not  put  your  fingers  into  your  mouth. 


Ai^D  HOW  to  COMBAT  IT. 


93 


Do  not  pick  your  nose  or  wipe  it  on  your  hand  or  sleeve. 

Do  not  wet  your  fingers  in  your  mouth  when  turning  the  leaves 
of  books. 

Do  not  put  pencils  in  your  mouth  or  wet  them  with  your  lips. 

Do  not  hold  money  in  your  mouth. 

Do  not  put  pins  in  your  mouth. 

Do  not  put  anything  in  your  mouth  except  food  and  drink. 

Do  not  swap  apple  cores,  candy,  chewing  gum,  half-eaten  food, 
whistles,  bean-blowers,  or  anything  that  is  put  in  the  mouth. 

Peel  or  wash  your  fruit  before  eating  it. 

Never  sneeze  or  cough  in  a  person's  face.  Turn  your  face  to  one 
side  or  hold  a  handkerchief  before  your  mouth. 

Keep  your  face,  hands  and  finger-nails  clean.  Wash  your  hands 
with  soap  and  water  before  each  meal. 

When  you  don't  feel  well,  have  cut  yourself,  or  have  been  hurt 
by  others,  do  not  be  afraid  to  report  to  the  teacher. 

Keep  yourself  just  as  clean  at  home  as  you  do  at  school. 

Clean  your  teeth  with  toothbrush  and  water,  if  possible,  after 
each  meal ;  but  at  least  on  getting  up  in  the  morning  and  on  going 
to  bed  at  night. 

Do  not  kiss  any  one  on  the  mouth  or  allow  anybody  to  do  so 
to  you. 

Learn  to  love  fresh  air  and  learn  to  breathe  deeply  and  do  it  often. 


The  A.  B.C. 

for  Chil- 
dren in  the 
Prevention 
of  Tubercu- 
losis. 


These  leaflets  should  be  read  at  regular  periods,  say  once  a  month, 
and  explained  and  commented  upon  by  the  teacher.  The  children 
should  be  allowed  to  keep  the  leaflets  and  take  them  home  to  their 
parents. 

In  schools  where  slates  and  lead-pencils  are  given  to  the  children 
and  collected  after  school  hours,  these  articles  should  be  disinfected 
before  they  are  again  distributed  to  the  pupils.  Not  only  the 
spread  of  tuberculosis,  but  far  more  contagious  diseases,  such  as 
measles,  diphtheria,  and  scarlet  fever,  may  be  prevented  among 
school  children  by  this  simple  precaution.  The  custom  in  vogue 
in  some  schools  of  having  every  child  use  a  suitable  envelope, 
so  as  always  to  have  the  same  pencil,  while  preferable  to  no  precau- 
tion at  all,  is,  in  my  opinion,  not  nearly  so  safe  as  a  thorough 
disinfection. 

On  playgrounds  and  in  corridors,  elevated  spittoons  with  auto- 
matic flushing  devices  and  cover  such  as  illustrated  in  Fig.  25, 


Disinfec- 
tions of 
Lead-pen- 
cils, etc. 


94 


TUBERCULOSIS  AS  A   DISEASE   OF  THE  MASSES 


Child-labor 
at  Home  is 
as  Perni- 
cious as 
that  in 
Factories. 


should  be  placed  here  and  there  to  remind  the  old  and  3^oung 
never  to  expectorate  on  the  ground. 

An  important  point  in  the  prevention  of  the  disease  under  con- 
sideration among  school  children  is  that  the  school  teacher  should 
be  familiar  with  the  objective  signs  and  s^'mp- 
toms  of  tuberculosis  and  the  characteristics  of 
a  person  predisposed  to  consumption. 

The  symptoms  have  been  described  at 
length  in  the  preceding  chapters,  XVIII. 
and  XIX.  The  duties  of  the  school  physi- 
cian should  be  a  daily  inspection  of  the  chil- 
dren to  avoid  the  propagation  of  acute 
infectious  diseases  including  bronchitis  and 
grippe;  the  constant  supervision  of  the  sani- 
tary condition  of  the  school  buildings;  regular 
visits  to  the  gymnasium  and  the  swimming- 
school;  and,  lastly,  the  most  unportant  func- 
tion of  all,  the  periodical  examination  of  the 
chests  of  all  pupils,  teachers,  and  employees  of 
the  school.  The  weeding  out  of  all  individuals 
that  might  constitute  a  source  of  infection, 
or  those  whose  treatment  becomes  an  impera- 
tive necessity,  and  the  advice  to  be  given  to 
the  parents  of  a  tuberculous  child,  will  make 
the  school  physician  a  most  important  factor 
in  the  solution  of  the  tuberculosis  problem. 

In  the  prevention  of  tuberculosis  in  child- 
hood I  have  always  looked  upon  the  sup- 
pression of  child-labor  as  one  of  the  prima-facie  necessities.  While 
it  is  with  a  sense  of  deep  humiliation  that  we  must  acknowledge 
that  this  curse  to  childhood  is  not  yet  entirely  done  away  with  in 
all  our  States,  it  is  gratifying  to  note  the  ever-increasing  progress 
toward  its  suppression. 

However,  there  is  one  kind  of  child  labor  which  the  law  can  only 
reach  with  difficulty,  except  as  it  has  the  co-operation  of  the  school 
teacher  and  the  school  physician.  I  refer  to  those  cases  where 
cruel  or  thoughtless  parents  impose  upon  their  often  delicate  chil- 
dren the  fulfilment  of  household  duties  or  the  performance  of  manual 
labor  which  would  task  the  strength  of  a  grown  jicrson.  The  timid 
child  will  probably  never  complain;  but  when  the  teacher  or  school. 


Fig.  25.  —  Knopf-Thi- 
bert  Elevated  Self-Flush- 
ing Spittoon. 


AND   HOW  TO  COMBAT   IT. 


Ö5 


physician  suspects  that  the  paleness,  the  stooping  shoulders,  and 
the  tired,  sad  look  are  the  results  of  excessive  manual  labors  im- 
posed upon  the  child  by  parents  or  guardians,  it  is  his  duty  to 
investigate  and  interfere. 

In  schools  located  in  the  districts  of  the  poor  where  under-feeding 
of  the  pupils  not  only  often  hinders  the  child  from  doing  good 
school  work,  but  actually  predisposes  to  tuberculosis,  I  would 
suggest  to  the  board  of  education  a  philanthropical  enterprise  in 
which  the  generous,  good-hearted  people  of  every  community  should 
gladly  join.  This  is  to  provide  these  half-starved  little  ones  with 
a  luncheon  of  one  or  two  meat  sandwiches  and  one  or  two  glasses 
of  good  milk.  I  am  convinced  that  fewer  will  develop  tuberculosis 
and  scrofulosis  and  they  will  do  better  work  at  school  and  at 
home. 

To  avoid  a  pauperizing  tendency,  a  few  pennies  may  be  charged 
for  these  lunches. 

What  shall  be  done  with  a  tuberculous  child  whose  presence  in 
the  public  school  m<ay  be  a  danger  to  his  comrades,  besides  making 
his  own  recovery  much  more  difficult?  Municipalities  and  philan- 
thropists should,  after  the  example  of  the  people  in  Europe,  create 
seaside  or  country  sanatoria  where  the  tuberculous  children  may 
not  only  have  the  best  possible  chance  of  becoming  cured,  but 
also  receive  the  necessary  education. 

On  pages  63,  76,  and  77  of  this  volume  I  have  spoken  at  length 
of  the  prevalence  of  tuberculosis  among  school  children  and  the 
admirable  work  which  is  accomplished  in  seaside  sanatoria.  Grati- 
fying results  have  also  been  attained  in '  inland  institutions  de- 
voted to  the  treatment  of  tuberculous  and  scrofulous  diseases  of 
children.  In  such  seaside  or  inland  sanatoria  for  children  the  un- 
fortunate teacher  also,  whether  predisposed  to  tuberculosis  or 
already  in  the  earlier  stages  of  the  disease,  may  find  suitable  em- 
ployment with  the  best  possible  chance  for  recovery. 

Installation  for  the  Sanatorium  Treatment  of  Con- 
sumptives AT  Home. 


In  Chapter  XXVII.  the  question  "Can  the  treatment  of  con- 
sumption be  carried  out  with  satisfactory  results  outside  of  an  institu- 
tion? "  has  already  been  answered  in  the  affirmative.  On  page  23, 
Chapter  V.,  we  described  how  the  consumptive's  room  should  be 


96 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Selection  of 
Eoom  for 
Tubercu- 
lous 
Patient. 


arranged,  and  in  this  supplement  it  is  our  purpose  to  give  additional 
suggestions  in  case  the  home  treatment  becomes  necessary  or  desirable 
and  show  how  the  sanatorium  treatment  can  be  imitated  as  nearly  as 
possible.  First,  one  should  bear  in  mind  that  the  sunniest,  best- 
ventilated,  and  most  comfortable  room  of  the  house,  preferably 
on  a  higher  floor,  is  the  best  suited  for  that  purpose.  All  super- 
fluous furniture,  dust-catching  curtains,  and  fixed  carpets  should 
be  removed,  but  the  room  must  not  be  made  cheerless.  A  few  rugs, 
washable  curtains,  some  cheerful  pictures  may  well  be  allowed. 


Fig.  ii6.— Dr.   S.   A.  Knopf's    VViiidow-tent    in   Position,   with  Patient   in  Bed  Looking 
through  the  celluloid  window  into  the  room,  but  breathing  outdoor  air  only. 

If  the  arrangements  illustrated  in  Fig.  22  and  Fig.  23  for  outdoor 
sleeping  at  night  and  the  rest  cure  in  the  open  air  by  day  be  added, 
so  much  the  better.  This,  however,  will  only  be  feasible  in  a  few 
Description  instances,  and  is  not  at  all  j^racticable  in  large  cities,  particularly 
,  .  "in  our  apartment-  and  tenement-houses.  To  make  the  o])en-air 
treatment  feasible  by  day  and  night  even  in  the  homes  of  the  poor 
living  in  cities,  I  have  devised  what  I  call  a  "Window  Tent."  It 
consists  of  an  awning,  which,  instead  of  being  placed  outside  of  the 
window,  is  attached  on  the  inside  of  the  room.  It  is  so  constructed 
that  the  air  from  the  room  cannot  enter  or  mix  with  the  air  in  the 


AND    HOW   TO   COMBAT   IT. 


97 


tent.  The  patient  lying  in  the  bed,  which  is  placed  parallel  with 
the  window,  has  his  head  and  shoulders  resting  in  the  tent  (Figs. 
26,  27,  28).  By  following  the  description  (Fig.  29)  closely  it  will 
be  seen  that  the  ventilation  is  as  nearly  perfect  as  can  be  pro- 
duced with  so  simple  a  device.  The  tent  is  attached  to  the 
frame  of  an  American  window,  but  it  does  not  quite  fill  the  lower 
half.  A  space  of  about  three  inches  is  left  for  the  escape  of  the 
warm  air  in  the  room.      By  lowering  the  window,  this  space  can 


Fig.  27.— Dr.  S.  A.  Knopf's  Window-tent  Raised  when  Not  in  Use. 

be  reduced  to  one  inch  or  less ,  according  to  need.  On  extremely 
cold  and  windy  nights  there  need  not  be  left  any  open  space  at 
all  above  the  tent  frame.  The  patient's  breath  will  rise  to  the  top 
of  the  tent,  the  form  of  which  aids  in  the  ventilation.  The  tent  is 
constructed  of  a  series  of  foul  frames,  made  of  Bessemer  rod  suitably 
formed  and  furnished  with  hinged  terminals;  the  hinges  operating 
on  a  stout  hinge  pin  at  each  end  with  suitable  circular  washers 
interposed  to  insure  independent  and  easy  action  in  folding  the 
same,  the  Bessemer  rod  being  hardened  to  make  a  stiff,  rigid  frame 
to  insure  its  maintaining  the  original  form. 


98 


TUBERCULOSIS  AS  A   DISEASE  OF  THE  MASSES 


The  frame  is  covered  with  extra  thick  yacht-sail  twill,  properly 
fitted,  and  having  elongated  ends  to  admit  of  their  being  tucked 
in  under  and  around  the  bedding  to  prevent  the  cold  air  from  enter- 
ing the  room.  The  patient  enters  the  bed  and  then  the  tent  is 
lowered  over  him,  or  with  the  aid  of  a  cord  and  a  little  pulley 
attached  to  the  upper  portion  of  the  window  he  can  manipulate 
the  lowering  and  raising  of  the  tent  himself.  Shutters  or  Venetian 
blinds,  whether  they  are  attached  on  the  inside  or  on  the  outside 
of  the  window,  can  be  utilized  in  conjunction  with  the  window- 
tent  as  a  screen  to  intercept  the  gazes  of  the  neighbors,  and  in  stormy 
weather  as  a  protection.  The  bed  can  be  placed  by  the  window  to 
suit  the  patient's  preference  for  sleeping  on  his  left  or  right  side, 
so  that  he  has  the  air  most  of  the  time  in  his  face.  Another  advan- 
tage of  the  window-tent  is  that  it  will  not  attract  attention  from 
the  outside.  The  bed  being  placed  alongside  of  the  window  will 
be  convenient  for  a  majority  of  the  poor  who  have  small  rooms. 
If,j  however,  the  bed  must  be  placed  at  a  right  angle  to  the  window, 

this  can  be  arranged  as  well. 
A  piece  of  transparent  cellu- 
loid is  placed  in  the  front  of 
the  tent  to  serve  as  an  obser- 
vation window  for  the  nurse 
or  members  of  the  family  to 
watch  the  patient  if  this  is 
necessary.  It  also  serves  to 
make  the  patient  feel  less  out- 
doors and  more  in  contact 
with  his  family,  as  he  can,  if 
he  desires  to,  see  what  is 
going  on  in  the  room.  If  the 
bed  must  be  placed  at  a  right 
angle  to  the  window,  the  ob- 
servation glass  can  be  put  in 
on  either  side.  It  goes  with- 
out saying  that,  as  a  rule, 
patients  should  not  smoke; 
when,  in  exceptional  cases, 
this  can  be  allowed,  the  danger  of  the  celluloid  window  becoming 
ignited  must  be  impressed  upon  them  and  the  greatest  precau- 
tion urged.     I  prefer  celluloid  to  glass  for  this  purpose,  because 


Fig.    28.— View  of  Winrtow-tent  and  Patient 
taken  from  the  outside. 


AND  HOW  TO  COMBAT   IT. 


99 


there  is  no  aanger  of  its  breaking  when  the  tent  is  raised  and 
lowered. 

If  it  is  necessary  to  raise  the  bed  to  the  height  of  the  window 
sill,  this  can  be  done  with  Uttle  expense.  If  the  bed  is  of  iron,  a 
few  additional  inches  of  iron  piping  can  be  attached  to 
the  legs  by  any  plumber  or  one  handy  with  tools; 
raising  a  wooden  bed  can  be  accomplished  with  eqaal 
facility.  If  the  window-tent  is  to  serve  the  patient  only 
during  the  night,  the  tent  can  be  pulled  up  and  the  bed 
moved  away  from  the  window  during  the  day,  and  the 
window  closed.    Or  the  tent  can  be  taken  from  the  hooks 

and  put  out  of  the  way. 
^'■'"^X  The  window-tent,  of  course,  is  of 

the  greatest  service  to  the  consump- 
tive sufferer  in  winter.  If  he  is 
feverish,  or  his  stay  in  bed  is  ad- 
visable, he  can  spend  his  entire  time 
in  the  tent.  If  the  people  are  poor, 
and  the  room  where  the  consumptive 
sufferer  lies  serves  as  living-room  for 
the  rest  of  the  family,  the  fact  that 
the  well  members  need  not  shiver 
while  the  patient  takes  his  open-air 
treatment  is  of  vital  importance 
in  many  respects.  While  the  room 
will  not  be  c|uite  as  warm  as  if  the 
window  was  entirely  closed,  it  wdll 
be  much  warmer  than  if  there  was  no  tent  in  front  of  the  win- 
dow. Laying  aside  the  economic  advantages  to  a  poor  family 
when  not  obliged  to  heat  more  than  one  room,  the  patient  feels 
that  he  does  not  deprive  his  loved  ones  of  comfort  and  warmth 
and  that  he  is  less  a  burden  and  hinderance  to  their  happiness. 
The  other  members  of  the  family,  on  their  side,  feel  that  they  can 
give  the  patient  all  the  air  he  needs  and  that  he  need  not  suffer  for 
their  comfort. 

In  winter  the  patient's  bed  must  be  covered  with  a  sufficient 
number  of  blankets  to  assure  his  absolute  comfort  and  warmth 
throughout  the  night.  .Still,  the  coverings  should  not  be  so  hea^T 
as  to  press  down  upon  the  body  and  make  the  patient  feel  uncom- 
fortable or  tire  him.     The  tightly  woven  blanket  is  a  better  pro- 


FiG.  29.— Diagram  Showing  Ventila- 
tion of  Window-tent. 


Adjust- 
ment of 
Bedstead 
to  Suitable 
Height. 


Advantages 
of  the 
Window- 
tent  in 
Winter. 


Warm  Cov- 
ering But 
not  too 
Heavy  is 
Essential. 


100  TUBERCULOSIS  AS  A   DISEASE  OF   THE  MASSES 

tection  than  the  loosely  woven  one.  To  the  poor,  whose  disposal 
of  blankets  is,  alas,  often  very  limited,  it  may  be  good  advice  to 
tell  them  to  put  several  layers  of  newspapers  between  the  coverings. 

Outdoor  Life  of  December,  1905,  recom- 
mends to  sew  half  a  dozen  layers  of  paper 
between  two  layers  of  flannel.  This  cer- 
tainly will  make  a  cheap,  light,  and 
warm  covering.  In  extremely  cold 
weather,  the  patient  while  sleeping  in 
the  window- tent,  should  wear  a  sweater 
and  protect  his  head  and  ears  with  a 
woollen  cap,  shawl,  or  woollen  helmet, 
such  as  is  showTi  in  Fig.  30. 

Some  patients  will  often  complain  that 
Fig.  30.— Woollen  Hood  or  Hei-    the  bright  light  awakens  them  too  early 
met  for  Out-Door  Sleeping  in    [^  the  moming,  and  that  they  have  diffi- 

Cold  Weather.  ,,       .  .  ,         ,  .  -r 

culty  m  going  to  sleep  again.  In  such 
instances  I  counsel  the  patient  to  have  some  light-weight  but  dark- 
colored  material  (such  as  a  black  lisle-thread  hose)  to  put  over  his 
eyes.  This  usually  suffices  to  obviate  the  inconvenience  caused  by 
the  bright  light. 

It  will  be  observed  that  by  merely  closing  the  window  and  rais- 

_-       ^,         ing  the  tent  the  iDatient  finds  himself  in  the  warm  room,  ready  for 
How  the      .°,  .,  ,  \  ,,  ,,  u 

Window-  toilet,  sponge-bath  or  massage  as  the  case  may  be. 

tent  can  When  there  is  no  garden,  veranda,  or   roof,  the  window-tent 

be  Utilized  can  also  be  put  into  service  for  the  rest  cure  during  the  day.     The 

for  the       bed  is  moved  away,  and  the  reclining-chair  put  in  its  place.     The 

Rest  ture    jj^^ter  can  be  raised  to  the  necessary  height  by  wooden  blocks  or  a 

■n    1-   •         platform,  and  with  the  aid  of  blankets  and  comforters  the  air  from 

Chair  by     ^^®  room  can  be  excluded,  and  the  patient,  being  in  front  of  the 

Day.         open  window,  breathes  only  outdoor  air.     When  beginning  this 

aerotherapy,  it  is  of  course  essential  that  it  must  be  done  graduall}^ 

according  to  the  susceptibility  of  the  patient  to  the  cold.     It 

should,  however,  be  impressed  upon  him  that  night  air  is  as  pure 

as  day  air.     It  is  best  to  begin  by  placing  him  in  the  tent  for  a  few 

hours  at  night,  and  a  few  hours  during  the  day  in  the  chair.     The 

attending  physician  will  regulate  all  this  so  as  to  get  the  patient 

gradually  accustomed  to  live  in  the  pure  cold  air  day  and  night. 

A  hot-water  bottle  for  the  feet  either  in  bed  or  in  the  chair  may 

often  be  necessary  in  extreme  cold  weather.     The  patient's  feet 

must  be  kept  warm  if  he  is  to  benefit  by  the  open-air  treatment. 


AND   HOW  TO   COMBAT   IT. 


101 


I  Historical  Review  of  the  Antituberculosis  Movement 
IN  THE  United  States. 

The  first  private  sanatorium  for  tuberculous  patients  was  es- 
tablished by  Dr.  J.  W.  Gleitzmann  some  thirty  years  ago  (1875). 
It  was  followed  some  years  later  (1884)  by  the  establishment  of 
the  first  sanatorium  for  the  consumptive  poor  through  the  personal 
efforts  and  devotion  of  Dr.  E.  L.  Trudeau,  of  Saranac  Lake.  The 
first  sanatorium  established  near  a  large  city  and  without  regard 
to  any  climatic  advantages  was  the  Sharon  Sanatorium,  near  Boston. 
It  was  opened  in  1890.  It  owes  its  existence  to  the  enthusiasm 
and  personal  work  of  Dr.  Vincent  Y.  Bowditch.  The  construction 
of  the  first  State  sanatorium  for  consumptives  was  authorized  by 
an  act  of  the  Legislature  of  the  State  of  Massachusetts  in  1895. 
It  is  situated  at  Rutland,  Mass.,  and  was  opened  for  reception  of 
patients  on  Oct.  1,  1898. 

Since  then,  and  particularly  during  the  past  five  years,  private. 
State,  and  municipal  sanatoria  have  been  established  in  many 
of  the  States  of  the  Union,  or  are  at  this  moment  projected  or  in 
course  of  construction. 

In  1903  there  was  established  at  Lake  Kushaqua,  N.  Y.,  an  in- 
stitution called  the  Stony  Wold  Sanatorium,  which  is  unique  of  its 
kind. 

It  owes  its  inception  to  the  thoughtful  wives  of  two  New  York 
physicians,  Mrs.  James  E.  Newcomb  and  Mrs.  Geo.  F.  Shrady; 
it  is  consecrated  exclusively  to  the  treatment  of  consumptive 
workingwomen  and  children  and  maintained  mainly  by  noble- 
hearted  women  of  wealth. 

The  first  seaside  sanatorium  for  tuberculous  and  scrofulous 
children,  called  Sea  Breeze,  was  established  a  few  years  ago  (1904), 
by  the  Society  for  the  Improvement  of  the  Condition  of  the  Poor, 
and  is  situated  on  Coney  Island. 

'Xhe  first  dispensary  class  in  the  United  States,  devoted  exclu- 
sively to  the  treatment  of  tuberculosis,  was  inaugurated  in  1894 
by  Dr.  Edward  J.  Bermingham  of  this  City,  at  the  New  York 
Throat  and  Nose  Hospital. 

The  first  municipal  dispensary  for  the  treatjnent  of  the  con- 
sumptive poor  was  established  by  the  city  of  New  York  under  the 
name  of  Clinic  for  Pulmonary  Diseases  of  the  Health  Department. 


First  Sana- 
toria for 
Consump- 
tives in  the 
United 
States. 


First  Sea- 
side Sana- 
torium for 

Tubercu- 
lous Chil- 
dren. 


First  Spe- 
cial Tuber- 
culosis Dis- 
pensaries. 


102 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


First  So- 
ciety and 
First  Com- 
mittee for 
Prevention 
of  Tuber- 
culosis. 


Tuberculo- 
sis Exhibi- 
tions and 
Their  Edu- 
cational 
Influence. 


It  was  started  mainly  through  the  initiative  of  Prof.  Hermann  M. 
Biggs,  the  General  Medical  Officer  of  the  city,  and  was  opened  March 
1,  1904.  Since  then  dispensaries  for  tuberculous  patients  have  been 
established  in  many  of  the  larger  cities  of  the  United  States. 

The  first  society  for  the  prevention  of  tuberculosis  was  the 
Pennsylvania  Society  founded  in  1892  by  Dr.  Lawrence  F.  Flick, 
who  was  also  its  first  president.  This  society  was  the  only  active 
organization  until  five  years  ago. 

The  first  Tuberculosis  Committee  of  the  Charity  Organization 
Society  doing  educational  and  relief  work  was  founded  in  1902, 
largely  through  the  efforts  of  Prof.  Edward  T.  De  vine,  Ph.D.,  the 
general  secretary  of  the  Charity  Organization  Society  and  the 
Tuberculosis  Committee's  first  secretary. 

To-day  there  are  at  least  15  State  organizations,  and  60  city 
societies  or  committees  all  devoted  to  spreading  the  gospel  of  the 
preventability  and  curability  of  tuberculosis.  , 

The  first  tuberculosis  exhibition  was  held  in  Baltimore  in  Janu- 
ary, 1904,  under  the  joint  auspices  of  the  Tuberculosis  Commission 
of  the  Maryland  State  Board  of  Health  and  the  Maryland  Public 
Health  Association.  This  exhibition  was  an  objective  presenta- 
tion of  the  history,  distribution,  varieties,  causes,  cost;  prevention, 
and  cure  of  tuberculosis.  The  next  most  important  tuberculosis 
exhibition  was  held  in  New  York  from  November  27  to  December 
9,  1905,  at  the  Natural  History  Museum.  The  exliibition  was 
organized  under  the  auspices  of  the  National  Association  for  the 
Study  and  Prevention  of  Tuberculosis  and  the  Committee  on  the 
Prevention  of  Tuberculosis  of  the  Charity  Organization  Society 
of  New  York.  Like  the  Baltimore  exhibition  it  was  planned  as  an 
educational  measure  in  the  wide-spread  campaign  against  tuber- 
culosis. It  showed  by  means  of  models,  photographs,  charts,  dia- 
grams, etc.,  the  main  facts  with  regard  to  the  disease  and  its  pre- 
vention and  cure.  Cooperation  from  all  parts  of  the  country  had 
been  enlisted  and  a  comprehensive  demonstration  of  the  facts  had 
been  installed.  On  the  opening  evening,  addresses  were  made  by 
the  Mayor  of  the  City  of  New  York,  the  Hon.  George  B.  McClellan; 
by  Dr.  Thomas  Darlington,  the  Commissioner  of  Health;  and  by 
President  Morris  K.  Jesup,  of  the  American  Museum  of  Natural 
History.  Since  then  the  same  exhibition  has  become  a  traveling 
one,  so  that  up  to  this  date  it  has  been  shown  in  Boston,  Philadel- 
phia, Newark,  Indianapolis,  Chicago,  Milwaukee,  Grand   Rapids, 


AND   HOW  TO  COMBAT  IT. 


103 


Manistee,  Detroit,  Toronto,  Cleveland,  Cincinnati,  Mexico  City, 
San  Antonio,  Minneapolis,  St.  Paul  and  Providence.  The  attend- 
ance at  these  exhibitions  has  been  a  total  of  nearly  five  hundred 
thousand.  Smaller  exhibitions,  organized  by  local  committees, 
have  been  held  in  various  cities  and  towns  and  materially  helped 
in  spreading  the  much  needed  information  concerning  the  pre- 
ventability  and  curability  of  tuberculosis. 

Four  journals  published  in  the  United  States  are  largely  devoted 
to  spreading  information  concerning  the  antituberculosis  move- 
ment and  sanatorium  matters.  These  are:  first.  Charities  and  the 
Commons,  published  in  New  York  under  the  auspices  of  the  Charity 
Organization  Society;  'second.  The  Journal  of  the  Outdoor  Life, 
published  at  Trudeau,  N.  Y.,  under  the  auspices  of  the  Adirondack 
Cottage  Sanatorium;  the  Open  Air  Quarterly,  published  by  The 
Open  Air  Quarterly  Company  at  the  Pembroke  Sanatorium,  Con- 
cord, N.  H.,  and  lastly  The  Vanguard,  the  monthly  bulletin  of  the 
Kentucky  Anti-Tuberculosis  Association. 

As  the  culmination  of  the  work  done  by  many  lay  and  medical 
men  and  women  devoted  to  the  noble  cause,  the  American  National 
Association  for  the  Study  and  Prevention  of  Tuberculosis  was  estab- 
lished at  a  meeting  in  Philadelphia  in  March,  1904,  and  the  organ- 
ization completed  in  June  of  that  year  at  the  time  of  the  meeting 
of  the  American  Medical  Association  at  Atlantic  City.  Dr.  Edward 
L.  Trudeau  was  elected  President;  Drs.  William  Osier  and 
Hermann  M.  Biggs,  Vice-Presidents;  Dr.  Henry  Barton  Jacobs, 
Secretary;  and  Gen.  George  M.  Sternberg,  Treasurer  of  the  asso- 
ciation. Among  the  honorary  vice-presidents  the  association  has 
the  good  fortune  to  count  the  Hon.  Theodore  Roosevelt,  President 
of  the  United  States,  and  the  Hon.  Grover  Cleveland,  ex-President 
of  the  United  States.  This  society  which  welcomes  as  members 
men  and  women  from  all  ranks  of  life  who  are  interested  in  the 
solution  of  the  tuberculosis  problem,  has  its  offices  in  New  York 
City  in  the  United  Charity  Building,  105  East  22d  Street.  Its 
present  executive  secretary  is  Prof.  Livingston  Farrand,  M.D. 

The  first  Institute  for  the  study,  treatment,  and  prevention  of 
tuberculosis  was  founded  in  Philadelphia,  Pa.,  in  1903.  It  owes 
its  existence  to  the  sagacious  munificence  of  the  well-known  philan- 
thropist, Mr.'  Henry  Phipps,  formerly  of  Pittsburg,  now  of  New- 
York. 

A  second  Tuberculosis  Institute  with  purposes  similar  to  those 


Journals 
Devoted  to 
the  Anti- 
Tuberculo- 
sis Move- 
ment. 


National 
Association 

for  the 
Study  and 
Prevention 
of  Tuber- 
culosis. 


Tubercu- 
losis 
Institutes. 


104 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES. 


Interna- 
tional Re- 
cent Tuber- 
culosis 
Congresses. 


of  the  Phipps  Institute  was  established  in  Chicago  in  1906,  mainly- 
through  the  efforts  and  enthusiasm  of  Dr.  Arnold  C.  Klebs,  who  is 
now  the  Head  of  the  Educational  Department  of  that  Institution. 

The  Medical  Profession  of  the  United  States  was  officially  rep- 
resented for  the  first  time  in  International  Tuberculosis  Congresses 
in  the  British  Congress  on  tuberculosis  in  1901.  Among  those 
who  represented  this  country  on  that  occasion  and  those  who  were 
honored  by  being  elected  as  vice-presidents  were  such  names  as 
Frank  Billings,  W.  J.  Councilman,  Charles  Denison,  George  Dock, 
W.  A.  Hare,  A.  Jacobi,  E.  G.  Janeway,  H.  M.  King,  H.  P.  Loomis, 
J.  H.  Musser,  Edward  O.  Otis,  Arthur  Rowley  Reynolds,  F.  C. 
Shattuck,  G.  B.  Shattuck,  E.  S.  Solly,  A.  K.  Stone,  Arthur  R. 
Thomas,  J.  Tyson,  S.  Weir  Mitchell,  W.  H.  Welch,  J.  C.  Wilson, 
and  others. 

At  the  International  Tuberculosis  Congress  which  convened  in 
Paris  in  1905,  the  American  Medical  Profession  was  represented 
by  an  official  delegation  appointed  by  the  President  of  the  United 
States,  composed  of  Drs.  Beyer,  Flick,  Jacobs,  and  Knopf.  There 
were  also  delegates  from  the  various  medical  centers,  among  whom 
were  such  men  as  Brannan  of  New  York,  Lowman  of  Cleveland, 
McCarthy  of  Philadelphia,  Pottenger  of  Los  Angeles,  etc. 

At  the  closing  session  of  this  congress  an  invitation  was  given  to 
have  the  next  Tuberculosis  Congress  meet  in  Washington  in  the 
fall  of  1908.  This  will  be  the  first  time  that  this  distinguished  body 
will  honor  our  country  by  its  presence,  and  the  American  Medical 
Profession  as  well  as  the  Public  at  large  should  rejoice  in  the  dis- 
tinction and  the  prospect  of  having  the  greatest  minds  engaged 
in  the  combat  against  the  White  Plague  soon  gathered  in  oui 
Capital. 


ERRATA 


On  page  12  (14th  line  from  the  bottom)  "  Villimin  "  should  be  "VUlemin." 

On  page  97  (6th  line  from  the  bottom  )  the  word  "foul  "  should  be  "  four." 

In  the  historical  chapter  the  following  items  were  inadvertently  omitted: 

To  the  names  of  the  Tuberculosis  workers  who  represented  the  American 
Profession  at  the  British  Congress  in  igoi  should  be  added  Drs.  Henry  J. 
Hartz  of  Detroit  and  M.  P.  Ravenel  of  Philadelphia. 

The  first  "Day  Sanatorium,"  where  patients  are  cared  for  from  8  in  the 
morning  until  5  in  the  evening,  was  established  on  Parker  Hill  in  Boston 
under  the  auspices  of  the  Association  for  the  Relief  and  Control  of  Tubercu- 
losis of  that  City,  in  the  summer  of  1905. 

The  first  Federal  Sanatorium  was  established  upon  the  recommendation  of 
Surgeon-General  Wyman  of  the  Marine  Hospital  Service  at  Fort  Stanton,  New 
Mexico,  in  1899.  Since  then  the  United  States  War  Department  has  estab- 
lished an  institution  for  tuberculous  soldiers  at  Fort  Bayard,  in  the  same  state. 

The  first  executive  order  with  a  view  to  preventing  the  spread  of  tubercu- 
losis among  the  employees  of  the  government  by  a  President  of  the  United 
States  was  issued  by  Theodore  Roosevelt,  Feb.  28,  1906. 


DATE  DUE 

6  W97 

OCT  2  71 

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